Almost every third person in Germany suffers from depression at least once in their life. However, most of them wait months for a therapy place. Digital health apps (DHAs) can help sufferers to bridge the long waiting times, but also to support psychotherapy. What the various apps are all about, who they are suitable for and how effective they actually are, is explained to us by Dr. sc. hum. Gwendolyn Mayer from Heidelberg University Hospital, Germany.
esanum: Ms. Mayer, how exactly can DHAs help to cope better with depression?
Dr. Mayer: Digital health applications support people in self-management. In concrete terms, this means that a good DHA responds to the patient's situation in an individualised way, for example by asking about mood and everyday events and activities on a daily basis. After a few days, an overview of the mood of the previous days is offered. In this way, patients can look for possible triggers that could explain a drop in mood. In technical language, we call this "mood tracking". It is known that depressed patients tend to put a negative filter over their memory. In retrospect, all the events of the last few days seem equally depressing to them. By keeping a precise record of their mood, it can become clear to them that fluctuations may well have occurred and what could have triggered them.
In addition, DHAs offer exercises for self-reflection or for structuring the day. It is precisely this that is often lost in depression. With the help of digital calendars, patients can plan positive activities that can help them to get out of a depressive valley in the long run. Last but not least, a good DHA also offers a lot of background information about the disease. Patients learn: I am not alone. A large percentage of people suffer from depression at least once in their lives and there are many ways to treat it!
esanum: In relation to digital health applications to combat depression, one often reads about "cognitive restructuring". How exactly does this process work?
Dr. Mayer: This is a technical term from cognitive behavioural therapy, one of the major schools of therapy for treating mental illness. Cognitive restructuring is about effectively interrupting automatic negative thought cycles and reshaping them. We all know automatic thoughts: We have forgotten something at home and are late for work. Already we think: "That's typical for me again, I'm always confused." Such thoughts are completely normal. But people who have slipped into depression can no longer defend themselves against the overwhelming power of their automatic thoughts. These are often messages they have been carrying around for a long time like "You're not worth anything!", "You'll never make it!" or "Who cares about you anyway?". These thoughts run on autopilot, affect the mood and first need to be discovered. DHAs offer helpful exercises for this, for example in the form of self-observation protocols. However, breaking through these thought patterns, revealing and changing subjacent beliefs is the subject of psychotherapy. It is unrealistic to expect that an app or a programme can do that.
esanum: Could DHAs compete with medical or psychotherapeutic treatment or are they rather to be understood as complementary?
Dr. Mayer: Personally, I don't see DHAs as competing with a real human relationship. But they can be used sensibly when people are waiting for a therapy place, for example, and urgently need help already. For example, this is currently the case for people in rural regions, where the supply of psychotherapists is often not very dense. The challenges of the COVID-19 pandemic and the resulting contact restrictions have once again increased the popularity of digital help for mental illness.
In addition, DHAs are also used as a supplement to therapy. We call this "stepped care". This means that the care of a mentally ill person starts with some psychotherapy sessions, a DHA bridges times in between and the results are then discussed again in therapy. A DHA could also be used as preparation for a stay in a clinic or for rehabilitation.
esanum: What is the concrete benefit of these applications for physicians and therapists - to what extent do they facilitate treatment?
Dr. Mayer: The "mood tracking" described above is often part of psychotherapeutic treatment anyway; in the past, patients were given self-observation protocols in paper form. Digital access makes it easier, especially for younger patients, to record their mood on a daily basis. Homework, such as an exercise on cognitive restructuring (see above), can also be given by physicians and therapists. The results can then be discussed in the next session.
Another advantage is psychoeducation: Background information on the disease is stored in a DHA in the form of text or video and no longer needs to be explained by physicians and therapists. However, caution is also called for here. Of course, even with a DHA, it is still up to the physicians and therapists to check whether the information has been accepted and understood.
esanum: Are there reliable data that prove the effectiveness of apps in dealing with depression?
Dr. Mayer: Meta-analyses on this topic are published at regular intervals, which prove the effectiveness. You need to know two things about this: A distinction is made between so-called "guided" and "unguided interventions", i.e. accompanied and unaccompanied interventions. In the former, there is the possibility of direct contact with a therapist via chat or email within the app or programme. In effectiveness studies, these are superior to pure self-management programmes without therapist contact. A meta-analysis of 39 studies recently published in JAMA Psychiatry was able to prove this, especially for patients with moderate depression. Patients with mild symptoms can therefore also benefit from unaccompanied programmes.
On the other hand, effectiveness studies are often conducted in such a way that one group of patients receives the digital intervention while the other group is still waiting for the intervention. We refer to this as a "waiting list control group". It is not too surprising that patients do better after a digital intervention than those who did not receive anything. Good studies therefore choose a more meaningful control group, for example a group that uses an online forum about depression during the same time that the intervention group is testing the app. Studies of this kind are rarer, but the effectiveness of apps could certainly be shown here. However, digital apps do not stand up to comparison with interpersonal, face-to-face psychotherapy.
esanum: Are there any contraindications to the use of digital applications for depression?
Dr. Mayer: Unfortunately, there are still few usable research results on this. It is clear, however, that DHAs are used more by younger and somewhat more educated patients, and that people with a migration background often do not cope so well with them. This has to do with the linguistic understanding that is often assumed.
A recent study in Psychiatry Research has just confirmed that in a representative sample from the USA, it is mainly female subjects with an annual household income of over 75,000 USD and a higher level of education who use health apps.
esanum: How do good apps differ from bad ones?
Dr. Mayer: If I type in "depression" in the app store on my smartphone, I get several hundred hits with apps that deal with the topic of mental or psychological health. They range from mood diaries to instructions for self-hypnosis to meditation apps. There is nothing wrong with using an app to support meditation. However, you should not expect it to have any particular therapeutic value for depression that needs treatment.
You should not judge the quality of an app by the number of positive stars. It is important to be clear about the developers who offer the product. These are usually listed in the imprint of the respective website. High-quality apps have been developed by clinical experts and their effectiveness has been tested in studies. A search in a scientific database with a simple search query for "App XY" is always worthwhile. It should also be checked whether the application is listed in the DHA directory of the German Federal Institute for Drugs and Medical Devices (BfArM). However, this is still under construction and currently (as of October 2021) contains 23 apps, 11 of which address mental health issues. These have been checked with regard to quality and data protection.
A minimum requirement for a good app is crisis management! In a depressive episode, there can be massive mood swings up to suicidal thoughts and concrete attempts to hurt oneself or take one's own life. A good app should contain an emergency programme that reacts to such crises and then refers to a hotline or, even better, offers the option of storing personal emergency contacts beforehand.
My advice to all physicians is therefore: Try out every app you want to prescribe yourself for a few days and pretend that you are having suicidal thoughts. Only serious cases like this will show you whether you can recommend the programme or not.
esanum: What do you consider to be the greatest opportunities and risks in using DHAs to treat depression?
Dr. Mayer: In my opinion, the greatest opportunities of DHAs for patients with depression lie on two levels: On a global, societal level, the opportunity clearly lies in the destigmatisation of the topic. The wide range of apps and programmes against depression shows that it can affect anyone and that there is a great need for help. Our own work in Heidelberg has shown that the inhibition threshold to seek therapy can possibly be lowered by an app or DHA.
On an individual level, DHAs can help depressed patients to support their self-management, promote their independence and also provide sound background knowledge. Some researchers speak of "patient empowerment". At the same time, however, this autonomy is the greatest risk: Patients can feel left alone, especially in a crisis. Some issues cannot be dealt with via an app; behind some depression there may be a traumatic experience or there may be an additional illness. Self-reflection may be strengthened online, but healing always takes place in real encounters.