Hero

Videos

Slideshows

Articles

Podcasts

Poll

The American Foundation for Suicide Prevention (AFSP) has contributed expertise and content on suicide to Most Days, a daily routine app that helps people track their mental health and well-being through different routines and provide support through the app’s community network. To discuss the upcoming collaboration, 

 sat down with Doreen Marshall, PhD, vice president of mission engagement for the AFSP and a licensed psychologist.

Psychiatric Times (PT): Most Days is the AFSP’s first collaboration in the mental health digital app space. What makes this app special?

 While there are many apps in the mental health space, it is important that app developers work with mental health experts and clinical providers to ensure that the content being provided actually does support mental health. Most Days approached AFSP with a desire to improve their app’s content in terms of suicide prevention and suicide grief. They also clearly communicated that the app is not a replacement for professional treatment and are eager to share resources that would help those in crisis get the help they need. After many discussions, we felt that a collaboration would help bring needed resources as well as support to individuals who may not be aware that these resources exist.

PT: You drafted the 4 routines related to suicide prevention for Most Days: (1) Thoughts of Self-harm or Suicide, (2) Healing After Surviving a Suicide Attempt, (3) Supporting Others Who May Have Thoughts of Self-harm or Suicide, and (4) Grieving Loss of a Friend or Family Member from Suicide. Could you tell us more about the routines and their accompanying resources? How did you pick these 4 routines?

 We know that when people are struggling with their mental health, it can be difficult to adhere to a daily routine that helps them. We also know that small actions matter. Most Days has a number of expert-developed routines that support mental health for those struggling with depression, anxiety, sleep problems, and grief. We thought that if we could build additional habits into the routines to help people based on what we have learned, it would help support suicide prevention and suicide grief work.

The habits we added will guide individuals toward actions that can support their other efforts to help themselves or others. For example, reminders to take medication as prescribed, review one’s safety plan, take steps to stay connected, can all have a positive impact on one’s mental health and may even save a life. Again, while using the app is not a substitute for working with a mental health professional, using an app to track habits and to connect to a supportive peer community can encourage people to proactively take daily steps to help their mental health.

We also thought there might be similar routines that could help support those who are caring for others or grieving a suicide loss. AFSP engages in several program efforts to educate the public about supporting those who may be struggling or grieving a suicide loss. Incorporating similar information into an app seemed to be an important way to extend these efforts to reach more people.

Finally, part of this collaboration was to include resources that can help someone who approaches the app and needs immediate support, so we incorporated the National Suicide Prevention Lifeline, a phone line that provides access to crisis counseling, to appear when someone engaged one of the suicide prevention related routines.

PT: How do routines help maintain an individual’s mental health?

 There is good research to support that maintaining a daily routine can support one’s mental health. When we are not experiencing optimal mental health, it can be more difficult to do the very things we know help us. Yet, we know that our daily actions matter, and things like remembering to take prescribed medication, getting some daily exercise, and reaching out to others can all have a positive impact on our mental health. Routines and prescribed daily habits can also help anchor us and provide some sense of control when we feel overwhelmed or unable to think about the next thing we can do to help.

PT: Part of the Most Days app’s appeal is the community aspect. Could you elaborate on the importance of communal support in building self-care routines?

 I think we all do better knowing there is support whenever we are trying to make a positive change. Most Days has a community of people who are actively trying to make positive changes to support their mental health, and for someone trying to do the same, it can help to know that others are working through similar challenges and that you are not alone.

PT: How can apps like Most Days build upon the clinical treatment patients receive?

 This is an important caveat for the use of apps related to mental health—they are not to be used instead of clinical treatment, but rather as an adjunct to treatment when treatment is needed. We know, though, that clinical treatment is usually limited—you may see an outpatient mental health professional for an hour a week, but you have lots of other hours outside of treatment to navigate your daily life and put into practice what you are learning in treatment. Apps that help track daily habits can help clients with reminders to engage in those helpful actions, as well as help them track their own behavior outside of treatment to be able to report accurately what they are experiencing to their clinical provider. And it always helps treatment when patients can accurately describe what is happening in between treatment sessions, which can be especially hard for patients to do when feeling depressed or struggling with their mental health.

PT: Finally, what is the most important thing about Most Days that you think mental health clinicians should know about?

 Apps cannot and should not replace clinical treatment when that is what is needed. But I think clinicians can consider how these existing mental health apps may support treatment efforts. They can work with patients to identify apps that are evidence-informed and contain expert content and resources. We should also remember that our patients are not the only ones that can benefit from apps to support our mental health—they can be helpful to us as clinicians in managing our mental health, too.

is vice president of mission engagement for the AFSP and a licensed psychologist.

The American Foundation for Suicide Prevention collaborates with Most Days, a mental health app, to provide suicide prevention expertise and content. Learn more about the partnership here. 

Mental Health App Collaborates With the American Foundation for Suicide Prevention

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.

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.

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.

 is a Clinical Associate Professor and Director for the Direct Entry Master’s in Nursing, Evidence-Based Nursing and Clinical Nurse Leader programs at the University of New Hampshire, Durham. Her research interests include the use of Health Information Technology such as mHealth in support of health equity initiatives.

Interrater reliability of mHealth app rating measures: analysis of top depression and smoking cessation apps.

2. Martinengo L, Van Galen L, Lum E, et al. 

Suicide prevention and depression apps’ suicide risk assessment and management: a systematic assessment of adherence to clinical guidelines.

3. Stawarz K, Preist C, Tallon D, et al. 

User experience of cognitive behavioral therapy apps for depression: an analysis of app functionality and user reviews.

4. Munoz Ramos R, Ferrer Cheng PG, Jonas SM. Validation of an mHealth app for depression screening and monitoring (psychologist in a pocket): correlational study and concurrence analysis.

Ehealth interventions for the prevention of depression and anxiety in the general population: a systematic review and meta-analysis.

6. Tangari G, Ikram M, Ijaz K, et al. 

Mobile health and privacy: cross sectional study. 

Predicting suicide following self-harm: systematic review of risk factors and risk scales. 

8. Stern TA, Rosenbaum JF, Fava M, et al. 

Massachusetts General Hospital Comprehensive Clinical Psychiatry

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

Challenges with mHealth Apps for Depression and Suicide Prevention 

In a 2016 review, there were more than 165,000 mHealth apps available to patients on the market.

 A review published just 3 years later noted the availability of 259,000 mHealth apps worldwide.

 Of the rapidly evolving app market, mHealth apps are among the fastest-growing groups, with an annual estimated growth rate of 32.5%.

 mHealth apps focused on mental health are one of the most prominent categories.

 These apps can be obtained for numerous device types and through the Apple iTunes/App Store or Android Google Play App Store.

There is currently no standardized review process to evaluate mHealth apps for quality or accuracy of information.

 There are also no centralized repositories for app reviews and ratings, and no type of standard app rating process or procedure.

 Current rating systems are based solely on app user ratings, which often are focused on design, interface, and usability. The evidence base of the information contained in these apps is not externally reviewed or verified as part of a requirement of implementing an app and getting it on the market.

 Relatively few apps have been through the rigor of a clinical trial.

The United States Food and Drug Administration (FDA) does not offer guidance for mHealth apps, and the FDA has indicated no plans to begin to regulate apps, especially as the FDA has deemed many to be 

 Between the FDA and European regulatory bodies, only 8 mental health apps have been approved.

 The FDA provides minimal guidance related to the post-market management of medical devices, which include mHealth apps, to consider risk management and utilize necessary steps to secure patient information.

 However, there is a lack of ongoing guidance and regulation in this area for app developers to utilize. There is also a lack of clear, consistent privacy policies and transparency with app users about how their information may be used and transmitted to third parties.

 continues to increase. There have been several approaches and foci for these apps. Some of the existing mHealth apps on the market related to depression include a focus on preventing depression, screening for depression, and supporting treatments with depression; there is even a 

 Currently there is no guidance, position statement, or even clear guidelines related to mHealth apps addressing psychiatric conditions from major national professional organizations such as the American Psychological Association and the American Psychiatric Association.

The mHealth apps are not consistently included in the same categories of the app store; some are listed in “Health and Fitness” categories, whereas others are indicated to be within the “Medical” category.

 Studies reviewing health app quality have found that apps are not consistently utilizing evidence-based clinical information or verified decision support tools.

 The inconsistent categorization of these apps further demonstrates the impact of the business and marketing perspectives on this area. The app development world is often approached from a strategic standpoint of business and marketing, which can pose a challenge when apps are potentially looking to address serious medical issues.

 address those currently diagnosed with the medical condition, and a randomized controlled trial by Deady et al

 evaluated the efficacy of a new app to reduce and even prevent depressive symptoms within a working population in Australia. The results were statistically significant in the app’s efficacy during the period of the trial, which included follow-up until 12 months post-baseline assessment.

The reported focus and aims of some of the mHealth apps addressing depression are either to complement traditional psychotherapy or to replace traditional therapy.

 A review and analysis conducted by Stawarz et al

 specifically reviewed apps that indicate a basis on 

 (CBT), which is an evidence-based treatment for depression along with other mental health conditions. However, within the review, there was significant variability in the context and intentions of the apps, along with inconsistent utilization of the evidence-based elements of CBT. As noted by other app reviews, there is an identified glaring gap regarding how

 and other technologies can engage with patients who may be experiencing complex conditions.

Given the numerous barriers to accessing care, especially timely care, there has been some research focused on the potential for apps to be utilized as a 

 A team of researchers conducted a comprehensive assessment of available suicide prevention apps on Google Play and the Apple App Store, and evaluated the suicide prevention content contained within depression management apps.

 Martinengo et al completed a systemic review utilizing descriptive statistics, evaluating the function and reliability of the apps.

 The initial pool of apps screened for use was over 2500 prior to deduplication; after 2 rounds of screening and subsequent systematic assessment, 69 apps were selected to be analyzed in the study.

Within these apps, some used validated, evidence-based tools such as the Patient Health Questionnaire-9 (PHQ-9), and some utilized chatbots to analyze suicidal behavior.

 Some of the apps that address depression symptoms may incorporate 

 or prevention content. Both providers and patients are interested in the potential to effectively utilize these tools to support mHealth apps assisting in managing depression.

In the ever-evolving digital world, interest in utilizing mHealth apps is occurring in patients along with health care providers. If health care providers have their patients ask for an opinion about a particular supplement. For example, if patients ask about a particular supplement, their providers will give an overview of the supplement including the lack of FDA regulation compared to other pharmaceutical medications to inform their shared decision-making. Currently, and for the foreseeable future, patients will ask their health care providers about some of these mHealth apps. As health care providers are busy in an increasingly complex health care environment, chances are providers do not have the time or bandwidth to thoroughly investigate what is available. With the sheer thousands of apps available, it would be impossible to remain current and provide our patients with an informed overview or answer. Providers must be cautious about recommending or endorsing these apps as well, as it can potentiate legal, ethical, or professional risk if the recommendation is in appropriate due to possible negative patient outcomes.

Patients struggling with their mental health, whether they are formally in psychiatric treatment or not, may find that the ability to access help in the palm of their hand is quite appealing. However, the plethora of available apps is likely overwhelming for someone dealing with 

, as one of the prevalent symptoms can be difficulty concentrating and making decisions.

 Often, when faced with so many choices without a prior recommendation, the app user will likely decide which app to utilize based on user review ratings. The user reviews do not take into consideration the validity or reliability of the app content, or whether it is evidence-based. Ratings and reviews are often based on app cost, visually appealing properties, reliability, minimal freezing or crashing of the app, and ease of signup, amongst other factors. There is no requirement or consideration for the scientific validity of the content and interventions within the app. As such, a highly rated app with many downloads may be enticing for someone interested in trial use, regardless of the fact that the app may not be evidence-based and may lack external validity to support its use. The current system of app ratings and oversight lacks transparency from experts to convey this information to consumers.

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. 

2. Munoz Ramos R, Ferrer Cheng PG, Jonas SM. 

Validation of an mHealth app for depression screening and monitoring (psychologist in a pocket): correlational study and concurrence analysis

3. Martinengo L, Van Galen L, Lum E, et al. 

4. Tangari G, Ikram M, Ijaz K, et al. 

Preventing depression using a smartphone app: a randomized controlled trial.

6. Stawarz K, Preist C, Tallon D, et al. 

Diagnostic and statistical manual of mental disorders

How can these mHealth apps help in the treatment of depression? 

Treating Depression and Preventing Suicide: The Impact of mHealth Apps

In the United States, 21% of adults (52.9 million) are estimated to have experienced a mental health disorder within a given year.

 The response to behavioral health needs in US communities is inadequate, which has created a gap between the need for treatment and the delivery of care: Of the 52.9 million adults with any behavioral health disorder, only approximately 16.9% (41.4 million people) received inpatient or outpatient behavioral health services within the year prior to the 2020 study.

For decades, access to behavioral health care providers in the United States has been a concern due to difficulty recruiting and retaining providers and the aging-out of the workforce.

 Other barriers for access to mental health care include cultural factors, 

, financial/insurance barriers, transportation, childcare, and fear or hesitation due to prior negative experiences.

Access to care has been even more negatively impacted by the 

—a time when mental health conditions have increased and worsened nationally.

 Although service delivery methods such as telehealth have grown substantially amidst the COVID-19 pandemic, the increase in availability has not been sufficient to meet the need for patient care, and access to mental health care services has continued to decline.

 is one of the most prevalent mental disorders in the United States, and it impacts individuals throughout the lifespan. Based on data obtained from the 2020 National Survey on Drug Use and Health (NSDUH), approximately 21 million adults have experienced at least 1 major depressive episode in their lifetime.

 Based on the survey findings, 14.8 million adults had experienced 1 major depressive episode resulting in significant, severe functional impairment within the past year.

 The prevalence in adolescents (ages 12 to 17) is concerning as well. An estimated 17% of adolescents have experienced at least 1 lifetime major depressive episode, and, according to the 2020 data, approximately 12% of adolescents in the United States had a severe depressive episode within the previous year.

Treatment in both adolescent and adult populations is comparably quite lower than the prevalence, relative to how many individuals are suffering. It was estimated that of the adults with major depression, 66% received treatment within the prior year based on 2020 survey data with the adolescent population, only 41.6% received treatment.

Linked to numerous disorders, including major depression, 

 is a devastating consequence of several mental illnesses and distress. Estimates of prevalence vary, but almost 1 million people worldwide die each year of suicide, and there are an estimated 16,000,000 suicide attempts.

 These numbers are likely underreported and the actual prevalence is much, much higher. Approximately 40% of individuals experiencing suicidality do not have access to medical care or do not seek it out.

Concurrently with this crisis in mental health care, there is a current rapid expansion of technology across sectors. One of these developments is mHealth, which captures the use of 

 and other portable devices provided with functions to manage one’s health, most often utilizing an application.

 The availability and presence of these apps is constantly growing, and many target a specific illness or condition, or a particular health behavior to provide a framework for monitoring and managing that condition.

This 3-part series will further evaluate mHealth apps that are available to address depression. The history of these apps, the use of the apps, identified challenges and barriers, and an overall synthesis of best practices based on the best available data at this time will be discussed.

1. Center for Behavioral Health Statistics and Quality – Substance Abuse and Mental Health Services Administration. Highlights for the 2020 national survey on drug use and health. September 2020. Accessed March 8, 2022. 

https://www.samhsa.gov/data/sites/default/files/2021-10/2020_NSDUH_Highlights.pdf

2. Bishop TF, Seirup JK, Pincus HA, Ross JS. 

Population of U.S. practicing psychiatrists declined, 2003–13, which may help explain poor access to mental health care.

3. CMS data shows vulnerable Americans forgoing mental health care during COVID-19 pandemic. Centers for Medicare & Medicaid Services. May 14, 2021. Accessed February 21, 2022. 

https://www.cms.gov/newsroom/press-releases/cms-data-shows-vulnerable-americans-forgoing-mental-health-care-during-covid-19-pandemic

4. National Institute of Mental Health. Major depression. NIMH Mental Health Information Statistics. January 2022. Accessed February 21, 2022. 

https://www.nimh.nih.gov/health/statistics/major-depression

5. Martinengo L, van Galen L, Lum E, et al. 

Nursing Informatics and the Foundation of Knowledge

 (4th ed.). Jones & Bartlett Learning; 2017.

How can mHealth apps help overcome barriers to access to care? 

mHealth Apps for Depression: Overcoming Challenges 

Suicide in late life constitutes a major public health concern. In 2019, the Centers for Disease Control and Prevention (CDC) reported that the suicide rate for all ages in the United States was 14.5/100,000. Middle-aged and older adults have higher rates of suicide than their younger counterparts (19.41/100,000 for individuals aged 55 to 64), and the highest rate of suicide remains for older males (39.9/100,000 for males aged 75 and older).

 Despite the alarmingly high rates, psychosocial interventions for this population are understudied and urgently needed.

Mobile devices provide a unique and powerful opportunity to deliver interventions to suicidal individuals during periods of increased suicide risk.

 With the current COVID-19 pandemic, reliance on digital health technology is growing, and developing targeted interventions that can be used remotely by older adults during times of emotional crisis is of paramount importance.

To establish effective psychosocial interventions, risk factors for late-life suicide must be examined. Sociodemographic and clinical factors that are more commonly found in middle-aged and older individuals (eg, widowhood, cognitive decline, etc) play an important role in suicide risk. Understanding the complex interaction of these late-life occurrences can guide efforts in designing preventative interventions.

According to the CDC, middle-aged and older adults account for the highest number of suicides compared to younger populations. In 2018, adults aged 65 and older were reported to make up 16% of the US population, but were responsible for 18.8% of suicides.

 While there are an estimated 25 suicide attempts for every completed suicide in the general population, approximately 1 in 4 suicide attempts results in death for older adults.

 Gender, race, and ethnicity also influence suicide risk and behavior. Women consistently account for a higher number of suicide attempts than men. There are 3 female attempts for each male attempt, yet an estimated 3.6 males die by suicide for every 1 female death. This discrepancy is attributed to the difference in method, because men often use more lethal methods when attempting suicide.

 In comparison to other racial and ethnic groups, non-Hispanic American Indian/Alaska Native and non-Hispanic white people account for the highest rates of suicide at 22.3 and 17.6/100,000, respectively.

Cognitive Functioning and Physical Illness

As many as 1 in 9 older adults suffer from some form of cognitive impairment.

 Cognitive impairment is often responsible for reducing decision-making capacity and affecting emotion regulation abilities, potentially contributing to suicidal ideation and behavior.

 Discrepancies in literature regarding suicide risk and cognitive impairment suggest that dementia can either be a risk factor or a protective factor depending on the progression and severity of symptoms.

 However, a review on suicide risk and Alzheimer disease found that Alzheimer disease is associated with a moderate suicide risk in older adults, even several years after diagnosis.

Physical illness and functional disability in late life are also strongly associated with suicide. In a cohort study by Erlangsen and colleagues,

 investigators found that certain cancers and liver disease, specifically, are most closely associated with suicidal outcomes. Despite strong associations found in research, reviewers of the literature advise caution when using physical illness to determine risk, many noting that identifying physical illness does not serve as a predictor for suicide, nor does quantifying the severity of symptoms.

Psychiatric Illness and Suicidal Behavior

Psychiatric illness is noted in up to 97% of late-life suicides, with major depression cited as the most strongly associated psychiatric disorder.

 Retrospective analysis of psychiatric illness and suicide mortalities in older adults in Denmark highlight recurrent depression as contributing to the highest rate of suicides in adults aged 60 and older, followed closely by other affective disorders and reaction to stress/adjustment disorders. This risk was significantly increased for individuals who were hospitalized for any type of psychiatric disorder, with hospitalized psychiatric illness accounting for 22.3% of male suicides aged 60 and older.

One of the predictors of suicidal behavior is suicidal ideation, especially active suicidal ideation with intent or plan. However, in older adults who are seeking aging services, even passive suicidal ideation is an indicator of suicide risk.

 Despite the elevated number of late-life suicides, suicidal older adults often go undetected due to lower rates of reporting,

 especially in primary care where older adults most likely seek medical treatment. This information highlights the need for increased identification strategies, as well as enhanced efforts to prevent the onset of suicidal ideation given the high mortality rate in late-life suicide attempters.

Interpersonal losses including widowhood or death of friends and family are commonplace in advancement of age. The accompanying stress, sense of loneliness, and social disconnection in response to loss is associated with elevated suicide risk, especially within the first year after the death of a close relative.

 Passive and active suicidal thoughts are particularly common among older adults in long-term care facilities, and social isolation and loneliness are some of the most frequently reported bases for suicidal thoughts.

 The relationship between perceived social support and psychiatric illness, most notably depression, is strong even when controlling for other factors, such as negative affectivity and overreporting of experiences.

 This points toward a need for more dynamic psychosocial interventions.

Existing Psychosocial Interventions for Suicide Prevention

Current randomized, controlled trials (RCTs) that evaluate psychosocial interventions for older adults are typically developed to address depression or other affective disorders in young adults and are not specifically targeted toward suicidality.

 Of the few published RCTs that measure suicidal ideation as a primary outcome in older adults, the intervention and assessment methods are diverse. Conwell

 investigated the effect of a peer companionship program on socially disconnected older adults, but saw no significant difference in suicidal ideation outcomes between the treatment and control groups. Two studies, conducted by Ecker

 evaluated adaptations of CBT on veterans with suicidal ideation. The first study was a 4-month brief cognitive behavioral therapy (CBT), and the second was CBT for depression compared against 2 other evidence-based psychotherapies. Both authors reported a reduction in suicidal ideation in the CBT/bCBT groups compared to control groups.

 examined suicidal ideation as a primary outcome in tests of problem-solving therapy in older adult populations. These studies both saw significant reductions in suicidal ideation in the treatment groups; however, 1 study tailored the intervention toward older adults with depression and executive dysfunction, and the other targeted subjects with functional disability, making the interventions difficult to compare.

Recent updates in suicide prevention interventions for older adults and how a novel tablet application may provide relief to individuals at high risk of suicide.

Digital Psychiatry

Mental Health App Collaborates With the American Foundation for Suicide Prevention

Challenges with mHealth Apps for Depression and Suicide Prevention

Treating Depression and Preventing Suicide: The Impact of mHealth Apps

mHealth Apps for Depression: Overcoming Challenges

Suicide in Older Adults: Advances and the Role of Technology in Treatment

Chatbots for Child Mental Health Care: Helpful, but Limited

Telepsychiatry: Diverse Needs Require Diverse Options

Prescription Digital Therapeutics and the Hunger for New Treatments

Surveying Attitudes Towards Digital Mental Health

Psychiatry in the Year 2500: Lessons Learned From History