How Technology Can Fill the Gaps in Our Mental Health System

Wait times for psychiatrists are often dangerously long. Why many Canadians are using apps to help treat their depression

Most Sundays, I feel hopeless. It’s a confluence of factors: the anticlimax of the weekend being over, the spectre of another week, and sometimes the effects of one drink too many the night before. My Sunday melancholy began in childhood, for years manifesting as hypochondria. I’d go to bed certain whatever affliction I’d diagnosed myself with that day would see me dead by morning. My misery was acute on Sundays, but other days, too, were bad. Through adolescence, my moods see-sawed between depression and a prickly anxiety that often veered into panic. In my twenties, I went on antidepressants and began weekly therapy. I also started meditating. With treatment, the hypochondria and the panic attacks stopped. The depression hung on, though, dogged if intermittent. No matter how well I feel, on Sundays, I am tugged toward despair.

But there are things that can help. For one, I always feel reassured after my therapist reminds me, later in the week, “Sure you felt like shit—it was a Sunday.” In my experience, depression tends to impede taking a long-range view; a single episode can be sufficiently wretched to make a miserable future feel inevitable. It’s easy, when depressed, to forget that there have been (and will be again) times of respite, or even joy. Working with a therapist helps me shed light on why I feel as I do, but it also helps me to track fluctuations in mood and draw insight from patterns that emerge. That, in turn, helps dislodge me from the belief that I’m a hopeless case.

In any given year, one in five Canadians experience a mental-health problem or illness. By age forty, about half the population will have, or has had, a mental illness. Thanks to financial or geographic restrictions, or both, however, many Canadians living with mental illness don’t have access to a therapist. Nowhere in Canada can clients be reimbursed for any visit to a counselor, psychotherapist, or psychologist who operates a private practice. If someone is lucky enough to have a private, employment-based insurance plans, these plans often cover only a handful of sessions. Meanwhile, a Mental Health Commission of Canada paper noted that about 80 percent of consultations with psychologists in 2001 took place within that privately funded system.

Psychiatrists in Canada are publicly funded, but access is often limited by long wait times. Across the provinces, the median wait time between referral and starting treatment is 19.4 weeks, according to a 2017 report by national think tank the Fraser Institute. The shortest waits were in Quebec (at 14.4 weeks) and the longest in Newfoundland and Labrador (at 93.5 weeks).

For some, the wait can be interminable, possibly fatal. According to the Canadian Mental Health Association, suicide is one of the leading causes of death in Canada, from adolescence to middle age. At the same time, research has shown that the type of therapy these professionals provide—often colloquially called talk therapy—is as effective as antidepressants in treating depression. Both appear to engage similar neural mechanisms, with the client-therapist bond acting as the main vehicle for expressing and resolving issues. To address the yawning gap between services and need, some Canadian hospitals, universities, and public-health agencies are investing in an innovative, and even radical, idea: talk therapy—but not necessarily with a person.

Smartphone apps could radically transform how our society intervenes in mental health. Just as there are apps that promise to hack one’s eating, transportation, and fitness routines, mental-health apps pledge to virtually address your psychological issues. Such apps enable users to chronicle thoughts and moods or self-administer popular therapeutic techniques like mindfulness, which is the process of bringing one’s attention to the present moment and a common technique used by therapists. Other apps employ cognitive behavioural therapy (CBT), which involves identifying and challenging one’s distorted thought patterns. Some are free; others charge a small monthly fee.

According to reports from Apple and Google, 2017 saw an unprecedented rise in the creation of mental-health, mindfulness and stress-reduction apps. What’s more, smartphone-accessible health care in general seems to be on the rise. In 2015, the IMS Institute for Healthcare Informatics counted more than 165,000 health apps on the market—and the number of Apple health apps has more than doubled from two years prior. About 36 percent of health apps, the largest portion, were fitness related. The next most popular apps targeted lifestyle and stress. And of the 9 percent geared to specific ailments, mental-health apps led.

Apps that target mental health focus on addressing everything from anxiety to depression, using a variety of methods and tools. There’s Happify, which, according to its Google Play profile, provides “effective tools and programs to improve your emotional wellbeing.” As of November, it’s been downloaded between 100,000 and 500,000 times (Google Play reports numbers as ranges, which makes an exact number difficult to pinpoint). SuperBetter, which claims to improve symptoms of anxiety and depression by having its users play their own lives as if they were a game, with point systems rewarding healthy behaviours and self-care, has had more than 100,000 downloads. PTSD Coach, which the United States Department of Veteran Affairs developed in 2011 to aid people with post-traumatic stress disorder, has been downloaded over 100,000 times in seventy-four countries.

In mental-health apps, the journaling or mood-tracking aspect is a prevalent tool. That makes sense, says Raymond Lam, a psychiatry professor at the University of British Columbia and director of the school’s Mood Disorders Centre. “People with depression/anxiety often have negative thinking patterns,” he says. “Tracking mood can provide some objective record of whether mood is improving.” Even if one’s symptoms are improving, without a record, “the person may only focus on those [symptoms] that are not.”

At a scientific level, the effectiveness of mental-health apps remains largely untested. But the prospect of the boon they’d give a deluged mental-health system is spurring a handful of Canadian institutions to invest in research that determines their impact. The windfall, if the apps work, is clear: low- and middle-income Canadians, and those living in remote or underserviced areas, could better access help. More broadly, the toll mental illness takes on the Canadian economy—the Mental Health Commission of Canada estimates it’s about $50 billion annually—would be alleviated.

In 2014, the Mental Health Commission of Canada recommended investment from Canadian stakeholders in e-mental health programs (apps are included under this umbrella, as are phone- and internet-based therapies). The commission is funding the rollout of a new mental-health-treatment model at over a dozen clinics in Newfoundland and Labrador. Developed over the past four years at Memorial University of Newfoundland’s Student Wellness and Counselling Centre, the premise of what’s called stepped care is to address mental illness with quick, simple solutions. If that doesn’t work, the next step is to try more complex approaches. The idea is to avoid treating every mental-health issue with intensive, months-long talk therapy, a traditional model that can overwhelm the system.

Over in Toronto, the Centre for Addiction and Mental Health, Sunnybrook Hospital, and SickKids are working together to build an app for youth with depression and anxiety. Psychologist Pamela Wilansky, the project’s lead researcher, knows that cognitive behavioural therapy is effective. But youth are typically reluctant to “drag out pieces of paper” and do the “homework” component of CBT. “We’re hoping clients will be more motivated to do this on their phones, which we know are basically attached to them,” she says. A prototype of the app, which youth and therapists consulted on, will be put through a randomized controlled trial. Half the participants will use the app in conjunction with in-person CBT, and half will simply do in-person CBT. If it’s found to generally reduce the intensity and duration of depression and anxiety symptoms, the app will be released for public use.

Galvanized by my research, I download Moodpath, the top-ranked app for the search term depression on the iOS App Store and the Google Play Store in Canada, the UK, Australia, and Germany. Launched in 2016, it’s been downloaded about 800,000 times to date, 310,000 of which were in North America. Throughout the day, it asks me questions. “Do you feel like you are not interested in anything right now?” “Do you have less or no appetite today?” I rate my mood on a scale ranging from “very bad” to “very good.” I am promised graphs that will map my mood’s permutations over seven days, then fourteen. It shows that, for a week, I am, on average, happier in the evenings than in the mornings. This feels mildly validating. I usually start the day tired and gloomy and only feel engaged and funny (what I fancy “myself”) in the late afternoon. But, after a couple of days, I lose interest. I’m frustrated by the time-consuming fact that, in order to see a summary of my depressive symptoms, I have to input data for fourteen straight days.

I mention my lack of motivation to Peter Cornish, a psychologist, professor, and director of the Student Wellness and Counselling Centre at Memorial University of Newfoundland. He cites a 2012 paper that looks at dropout rates for “computer-based psychological treatments for depression” that are accompanied by varying levels of support. The study found that the presence of human support reduced treatment dropout by 30 to 40 percent. A big part of what predicts successful mental-health programs, says Cornish, is having a caring person who understands you. Regarding apps, he notes, “Without some sort of expert guidance, users may waste time trying to find the right app, figuring out how to use it, and when to stop or try something else.”

Cornish is also the lead researcher on stepped care. He says the approach embraces experimenting with apps or other tools that are accessible and of interest to clients. If, for example, a client with anxiety brings in an app she’s found that offers relaxation techniques, the therapist would encourage her to use it and report back. Together, they can work with her lived experience to monitor its efficacy. This doesn’t mean Cornish gives wholesale approval to mental-health apps. “No one is keeping an eye on how to integrate apps into [therapeutic] practice in any structured way. Unless you do that, we don’t know how helpful they are in mental-health care.”

Evidence shows psychotherapy delivered virtually can be effective alongside human therapy, but less so by itself, Lam says. The Mood Disorders Centre in BC, he says, is in the process of converting to an app a website it designed for the public called MoodFx. It helps people monitor symptoms of depression and anxiety. A self-proclaimed “techie,” Lam has long been interested in how technology might augment clinical care, both as a way to engage patients and in recognition of the fact that the time most people spend with a psychiatrist or psychologist is very limited. What’s problematic, he says, is that, “a huge number [of apps] are doing a huge number of things, but we don’t know how well.”

Such is the main critique of mental-health apps: most haven’t been tested using broadly accepted models of scientific study, such as randomized controlled trials, in which participants are randomly assigned to either a group receiving the treatment in question or one getting what’s called a “sham treatment.” The American Psychiatric Association (APA) recently weighed in. It noted on its website in November 2016 that while apps offer “interesting possibilities for mental health with the potential to help monitor symptoms and some to even deliver adjunctive treatments,” many of the claims by mental-health apps have “never actually been studied or evaluated” nor are they regulated by the Federal Drug Administration.

Furthermore, the APA warns an app could offer misleading information, and the data it collects could be “improperly disclosed,” even sold. In November 2016, the APA posted an “App Evaluation Model” on its website, based on a framework developed by its smartphone-app evaluation working group. The idea is not to assign a rating to any particular app but to give clinicians parameters for deciding whether to use a specific app with a client or patient. It cautions clinicians: “The use of an app in clinical care is a clinical decision that depends on the patient at hand and your relationship with that patient. One app may be very useful for one patient but not another—just as one medication or therapy may be very useful for one patient but not another.”

I download another app, CBT Thought Diary. It functions like the CBT worksheets a therapist once gave me. A user ticks off the emotions they’re feeling and rates their distress on a one to ten scale. They can record their negative thoughts and identify cognitive distortions like “Catastrophizing,” “Jumping to Conclusions,” and “Minimization of the Positive.” They can also challenge bad thoughts using stock phrases like “I could be wrong about this” or “I could focus on the positive as well.” They then write an alternative interpretation of the situation and rate their distress level again, to see if it’s changed. I like the rote approach, but forget to log my entries most days, and—a blessing and a curse—there aren’t notifications hassling me to do so.

I call Mark Goering, a clinical psychologist in Berlin and the creator of the mental-health app, Moodpath, one of the apps I had tried earlier. I want to know what kind of role he envisions the app playing in the life of a person struggling with mental-health issues. Goering left a job in digital technology to become a therapist. After working in an in-patient psychiatric clinic, he missed the “vibe of startups” and decided to merge the two realms, confident smartphones were the way to go. While a paper medical assessment of depression might ask how often you slept badly this month, an app can ask how you slept every day for a month. “The validity of this data is higher,” Goering says, “as it’s taken from the natural environment of a person…not just while they’re sitting in a doctor’s waiting room.”

The app isn’t meant to replace a medical diagnosis, he said, but “to be used as an entry point to entering the professional health care market.” As it stands in Germany, he says, many people suffering from depression don’t seek medical help, and those who do often wait until they’ve hit a crisis point. Moodpath, however, seeks to have its users answer a number of questions for fourteen straight days—something I’ve not managed to do—to generate an assessment that may intervene before crisis. After fourteen days, it may say something like, “It looks like you have moderate, or severe, depression.” The idea is that a user may feel motivated to bring that assessment to a doctor. (Goering says his team is working on extending the functionality so a user can book online therapy appointments on Moodpath itself.)

The app is also CE-certified (meaning it conforms with European health-and-safety standards), and a pilot study done with the Free University of Berlin tested the app on patients to ensure it didn’t make depression worse. “Our quantitative and qualitative data showed the opposite,” Goering says. “People found it encouraging to see how their symptoms were developing. It countered the perception that their symptoms were always present.” This kind of data is important. Scientific validation of a treatment—the component many researchers say is missing from apps—is time consuming and expensive. The model Cornish is promoting centres on the idea that the type of therapy used is less important than its ability to respond to “the changing picture of a patient in a way that’s perceived as caring, encouraging, and positive.”

Several weeks into working on this piece, I plummeted into a depression. I told myself, “Now I’ll see if the apps work.” Nothing worked. For four days, I could barely get out of bed. Moving my body felt like trudging through molasses. I forced myself to answer Moodpath questions and watched the line graph representing my mood plunge. I felt a modicum of comfort when the app proffered questions that approximated my experience. Yes, I do feel inner unrest and agitation. No, I cannot focus on my tasks. On CBT Thought Diary, I pried thoughts from the muck of my sadness. “Life is futile,” I typed. Cue the cognitive distortions: I racked up twelve, starting with “All-or-Nothing Thinking” and finishing with “Labelling.” I challenged the thought with the app’s suggested, “most things are not black and white” and “my emotions may be clouding my judgment.”

I saw my therapist. She was wearing an emerald-green skirt that grazed her ankles. The radiators in her office, broken all day, came back on, and the room was balmy. She asked me a question that cut to the marrow of what I was feeling. I cried, opening a vein of relief. I felt lighter that night, then wretched for twenty-four hours, and then the depression appeared to lift. The next day, it was back, tenacious. Two days later, it retreated again, leaving me shaky but intact.

It’s true that the apps gave me some perspective when it came to the mild, day-to-day fluctuations of mood. But that experience taught me that when I was in the clutches of a serious depression, they didn’t do much. Unlike most Canadians, I am privileged. I have a therapist I meet with regularly, whom I trust. In the absence of other resources, it’s possible that a mental-health app could be, as the science journal Nature put it, a “digital lifeline,” especially to people in rural and low-income regions. The publication was reporting on the World Health Organization Mental Health Action Plan 2013-2020 recommending the use of electronic and mobile health technologies for “the promotion of self-care.” But the notion that an app would be someone’s sole mental-health resource is, frankly, terrifying.

As institutions evaluate mental-health apps in their current form, health researchers are already onto the next thing. Lam told me many in the field are excited about the prospect of smartphone apps to use “passive tracking” to determine a user’s mental state. This could mean measuring a person’s voice modulation or the number of texts they send to friends to build an assessment of their mood. It’s early days, and this technology hasn’t been sufficiently studied yet, Lam stresses. Digital mental-health intervention may never quite rival the curative effect of human therapeutic contact. Still, as Lam muses, “They say it’s going to transform health care.”

Jodie Shupac
Jodie Shupac is a Toronto-based writer. She has covered health, gender, and social justice.