Close to seven percent of Americans suffer from major depression, and 18 percent have an anxiety disorder. Many more experience subclinical symptoms of depression and anxiety throughout their lives. Despite this considerable healthcare burden, mental health issues remain largely undertreated.
At Northwestern Medicine’s Center for Behavioral Intervention Technologies (CBITs), investigators are striving to close this treatment gap by harnessing technology already in our pockets. The center, established at Feinberg in 2011 with a National Institutes of Health (NIH) grant, is dedicated to developing web and mobile technologies that help people make positive behavior changes for their health.
David Mohr, PhD, director of CBITs and a professor of Preventive Medicine in the Division of Behavioral Medicine, is leading one of the center’s key efforts: bringing mental health treatment straight to people’s smartphones. “Most people aren’t treated for depression — the average time from first onset of the disorder to first treatment is eight years,” Mohr says. “The hope is that by using technologies, we can find ways to deliver treatments that are both cost-effective and easily accessible.”
With more than 70 percent of Americans now carrying a smartphone, the device is a promising tool in the push to increase access to care. But there are challenges: While clinical trials have suggested that web and mobile technology can help people manage mental health issues in principle, it has often failed in practice.
Many of the apps currently available are poorly designed — cumbersome to use or dense with didactic material — and thus quickly abandoned by users.
“Generally people download a health app, they use it for a few days or a week, and then they get tired of it,” says Mohr, also a professor of Medical Social Sciences and of Psychiatry and Behavioral Sciences. “But that doesn’t work for behavior change, which requires consistent effort over many weeks and months.”
So in the spring of 2015, CBITs released a mental health program designed with engagement in mind: IntelliCare, a hub of 12 interactive smartphone apps that combat depression and anxiety with evidence-based strategies. The design better mirrors the way people use smartphones in their everyday lives.
“We realized that people tend to engage with most apps for a few seconds to get just one thing done,” Mohr says, like finding a destination on Google Maps or ordering dinner on GrubHub. Incorporating all of the strategies shown to effectively treat depression into one app would likely overwhelm and turn off users.
With that in mind, the team at CBITs decided to develop a suite of apps, with each individual app focusing on a single strategy that requires just a few minutes of time. One day users might find comfort in “Daily Feats,” a checklist that recognizes positive daily accomplishments. The next day, they might benefit from “Thought Challenger,” which borrows a strategy from cognitive behavioral therapy to help users identify a biased negative thought pattern and develop a more balanced perspective.
Eventually, IntelliCare will incorporate analytics that can make personalized recommendations for which app might be most appropriate for a user in the moment — “a Netflix for mental health apps,” Mohr explains.
ADDING A HUMAN TOUCH
While the sense of novelty that comes with receiving new recommendations is intended to keep users engaged, the team at CBITs also perceived that it might not be enough. “We can’t expect that a piece of technology alone is going to solve our behavioral health problems. As someone once told me, we’ve had scales for 100 years and people are still overweight,” Mohr says. “There needs to be some human engagement.”
To test this enhancement, the team conducted a trial, recently published in the Journal of Medical Internet Research, that paired IntelliCare with a dedicated coaching program. Trained coaches helped participants identify their goals over an initial phone call, and provided ongoing support via text message to check in, encourage use of the mobile tools and answer questions. Coaches also had access to a dashboard providing data on which IntelliCare apps their clients were using and when.
Kathryn Noth Tomasino, PhD, a clinical psychologist at CBITs, helped develop this aspect of the IntelliCare intervention. “We think coaching is a critical part of the experience,” Tomasino says. “We’re not trying to replace what people already do in therapy. Rather, we’re helping people build those skills into the context of their everyday lives, so they can practice them regularly and in the moment.”
The results of the trial were encouraging. Study participants improved to a degree similar to that expected from psychotherapy or antidepressants, Mohr says. The data also showed that participants stayed engaged: Use of IntelliCare apps remained strong and consistent for eight weeks — relatively rare for an app intervention.
The team is now conducting a controlled trial to confirm the results of this initial study and to investigate the impact of different levels of coaching.
Meanwhile, the IntelliCare suite, which is publicly available on Google Play, has been downloaded more than 30,000 times since its launch. While CBITs doesn’t collect data on the general population, they suspect the apps are reaching both people who use IntelliCare with therapy or medication, as well as those who simply don’t have access to traditional mental healthcare.
THE FUTURE OF MOBILE MENTAL HEALTH
IntelliCare is just one tool on CBITs’ growing roster of innovations. The center has collaborated on more than 60 projects and 35 NIH grants at Northwestern and beyond.
One major focus is investigating the value of smartphone sensors in predicting depression. For example, Purple Robot, a sensor app developed at CBITs, can collect GPS data on how much time someone spends at home and the variability of places they visit, factors correlated with depression.
“Right now when somebody is depressed — when they’re having a mental health problem that saps their motivation and leaves them feeling hopeless — the care system requires that they have the energy and impetus to go seek help,” Mohr says. “Ultimately, it’d be great if we could detect depression reliably enough that we could monitor people at risk and send some indication to providers who could then reach out.”
Down the line, sensors might even be able to address mental health problems automatically. “If we can detect behaviors related to depression, it allows us to then develop applications that become responsive — like a therapist in your pocket,” Mohr explains. “It could say, ‘It’s a sunny Saturday afternoon, and you’ve been sitting at home alone all day. Why don’t you go for a walk?’”
CBITs is also producing interventions as varied as MedLink, a tech-based approach to improving medication adherence, to a smartphone mental health program designed for homeless youth, led by Stephen Schueller, PhD, assistant professor of Preventive Medicine in the Division of Behavioral Medicine.
Tomasino recently conducted a controlled trial that found a web-based program for adults 65 and older — a high-risk group that’s often isolated — reduced depression over eight weeks.
“Technology can be very valuable in our public health efforts to reduce depression,” Tomasino says. “It can fit into the fabric of people’s lives in a way that therapy aims to, but doesn’t really have the reach to do so effectively. Our hope is that now, when someone is having that sudden overwhelming feeling of sadness or not feeling motivated, they have a tool that’s right at hand.”