Self-guided cognitive behavioral therapy apps for depression: Can they help? Systematic assessment of features, functionality, and congruence with evidence

Laura Martinengo, Anne Claire Stona, Paola Dazzan, Carmine Pariante, Florian von Wangenheim, Josip Car

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Abstract

Background: Mental health disorders affect one in ten people globally, of which around 300 million are affected by depression. At least half of affected people remain untreated. Cognitive behavioral therapy (CBT) is an effective treatment but access to specialized providers, habitually challenging, has worsened with COVID-19. Internet-based CBT (iCBT) is effective and a feasible strategy to increase access to treatment for people with depression. Mental health apps may further assist in facilitating self-management for people affected by depression, but accessing the right app might be cumbersome given the large number and wide variety of apps offered by public app marketplaces.
Objective: To systematically assess features, functionality, data security and congruence with evidence of self-guided CBT-based apps available in major app stores, targeting users suffering from depression.
Methods: A systematic assessment of self-guided CBT-based apps available in Google Play and Apple’s App Store was conducted. Apps launched or updated since August 2018 were identified through a systematic search in 42matters using CBT-related terms. Apps meeting inclusion criteria were downloaded and assessed using a Samsung Galaxy J7 Pro (Android 9) and iPhone 7 (iOS 13.3.1). Apps were appraised using a 182-question checklist developed by the research team, comprising apps’ general characteristics, CBT-related features, including six evidence-based CBT techniques as informed by a CBT manual, CBT competences framework and a literature review of iCBT clinical trial protocols (psychoeducation, behavioral activation, cognitive restructuring, problem solving, relaxation, and exposure for comorbid anxiety), and technical aspects and quality assurance. Results were reported as a narrative review, using descriptive statistics.
Results: The initial search yielded 3006 apps, of which 98 apps met inclusion criteria and were systematically assessed. There were 20 wellbeing apps, 65 mental health apps, targeting two or more common mental health disorders, including depression, and 13 depression apps. Twenty-eight apps offered at least four evidence-based CBT techniques, particularly depression apps. Cognitive restructuring was the most common technique, offered by 77/98 apps. Only a third of apps offered suicide- risk management resources while less than 20% of apps offered COVID-19-related information. Most apps included a privacy policy, but only a third of apps presented it before account creation. Eighty percent of privacy policies stated sharing data with third party service providers. Half of app development teams included academic institutions or healthcare providers.
Conclusions: Only few self-guided CBT-based apps offer comprehensive CBT programs or suicide risk management resources. Sharing of users’ data is widespread, highlighting shortcomings in the health app market governance. To fulfil their potential, self-guided CBT-based apps should follow evidence-based clinical guidelines, be patient-centered and enhance users’ data security.
Original languageEnglish
JournalJournal of Medical Internet Research
Publication statusAccepted/In press - 24 Apr 2021

Keywords

  • cognitive behavioral therapy, CBT, depression, mobile applications, apps, telemedicine, mHealth, self-guided CBT-based apps, self-management

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