Unguided Mental Health Self-help Apps: Reflections on Challenges through a Clinician's Lens

Abstract

The past one decade has witnessed a boom in the availability of Internet-based self-help apps in the field of mental health. Several apps have emerged that aim to provide information and strategies to empower individuals with self-help approaches to deal with issues and concerns related to mental health. A large number of these apps in developing countries are likely to be those which depend entirely on the users to go over the self-help program on their own (unguided internet-based self-help). Only a few apps add a component of periodic professional contact/technical support through phone/email or other means to supplement the self-help strategies suggested in the app that the user is expected to utilize. This scenario poses several challenges in use of unguided self-help apps for mental health. This paper enumerates some of these challenges for potential users of the apps from the perspective of clinicians. These range from difficulties in choosing the right app, limited scope for contextualization, and motivation management to awareness about when to step up to a higher intensity intervention. Despite these challenges, unguided self-help apps can serve important purposes, and hence we propose a few recommendations to address such challenges.

INTRODUCTION

The past few years has seen a boom in Internet-based interventions in the field of mental health with a steady stream of newer apps being introduced every year.[1,2,3] Treatment gap in the field of mental health is well recognized and Internet-based technologies are seen as offering huge opportunities to address treatment gap related to several factors such as lack of access to professional services, stigma, costs of availing services, time constraints, and low mental health literacy.[4] Clinical observations as well as emergent literature suggest that there is a segment of clients who are keen to explore the utility of mental health apps/narrate their attempts at trying them out.[5]

Both professionally assisted or guided self-help interventions as well as unguided Internet-based interventions are being developed for addressing various mental health problems as well as for mental health promotion. Unguided Internet-based interventions are those in which the user has to work through the material without any personal support. Professionally assisted interventions involve some level of contact with professional/trained personnel (face to face/chat/phone/mail) at the beginning/end or at various intervals to help the users complete the intervention program.[6] This is considered to be useful due to the role of human contact and therapeutic alliance that can help improve rates of compliance which are typically lower in unguided self-help interventions. There is cumulative evidence suggesting superiority of professionally assisted internet-based interventions, especially in the context of depression and anxiety though unguided interventions have also been found to serve useful purposes.[1,6,7,8] A bulk of mobile-based self-help intervention programs, especially in developing countries are likely to fall in the category of unguided self-help. Challenges and risks[9] entailed in the field of e-health interventions in general and in mental health, in particular, have been highlighted and a few guidelines/frameworks[2,10] for evaluating such newer technologies have also been published in the past few years.

Despite the possibility that unguided self-help apps may have only modest effects, their potential from a public health perspective is likely to be significant when these are adopted by a large number of individuals who may be in distress but are not availing any professional help in a given population.[6,11]

WHY FOCUS ON CHALLENGES RELATED TO UNGUIDED APPS?

We aim to touch upon various potential challenges and issues in the use of Internet-based unguided self-help interventions. These challenges are likely to be particularly salient in case of users who have not undergone any professional evaluation or are not currently receiving professional support. A scan of the growing literature on digital mental health as well as our engagement in the process of developing and pilot testing an Internet-based self-help program (Practice and Use Self-Help for Depression [PUSH-D]) for depression provided us an opportunity to reflect on the issues and challenges surrounding the use of mental health self-help apps. A recent review of Android apps for Indian users on self-help for depression revealed that most of these were informative and unguided in nature.[12] The process of recruitment of participants in the pilot trial of the PUSH-D program entailed announcements in various fora, subsequent to which individuals interested in participating in PUSH-D trial contacted the researchers for an initial evaluation session to determine the suitability of the app to address their issues. This process brought the research team in touch with individuals in the community who were experiencing various mental health issues but had often not yet sought professional help. We observed that during the sample recruitment process of PUSH-D trial, out of the first 106 individuals who contacted us to express interest in using the PUSH-D app for depression, 51% had never sought professional evaluation/consultation for mental health. Engaging in this process was a useful learning experience that provided opportunities to reflect and deliberate on use of Internet-based self-help programs, especially the unguided self-help programs. These potential challenges for naïve users are described below.

CHOOSING A SELF-HELP APP: CONFUSING ARRAY OF OPTIONS

The most basic challenge that naïve users are likely to face involves decision-making regarding which program to use, once they have decided to use a self-help program to deal with their mental health issues. There is a confusing array of options available, especially in the form of mobile apps for lay users. This is evident from our simple search on Google play store carried out in March 2017, like a potential user in India. The use of the search term “self-help for mental illness” yielded about 250 apps. The description provided in the play store as well as inside these apps did not indicate any professional assistance built into these apps as a supplement to self-help. Thus, to the best of our knowledge, these appear to be unguided self-help apps.

Although most of these self-help apps fall in the health/medical category; this broad categorization is not very helpful to users looking for specific kind of help within the health category. Number of downloads and user ratings are perhaps two indices most easily available to a potential users while deciding about the choice of apps. However, these indices are unlikely to indicate usability, efficacy, and potential utility for a given person. Moreover, user ratings are often based on highly variable number of users per app, thereby making comparisons difficult.[13]

Users can be helped in decision-making through adequate and specific description of what can be/cannot be expected from a self-help tool. Lack of this information can result in choices which may delay appropriate help seeking. For example, an unguided self-help intervention for depression may have limited utility for a user with severe depression or another user with depression in the context of severe marital discord or for someone with comorbid mental health conditions such as panic disorder or hypochondriasis. There is a need for user guides that can facilitate the process of decision-making for potential users of Internet-based mental health self-help programs. In addition, features such as screening of severity and complexity of the problems can be inbuilt into the initial section of unguided apps to generate feedback for the users regarding suitability/sufficiency of low-intensity intervention such as self-help.

LIMITED SCOPE FOR CONTEXTUALIZATION

The users who have never sought professional help may not realize/may underestimate as to how direct face-to-face interventions can provide a more contextualized approach as compared to self-help interventions which tend to be generic in nature. For example, mild-to-moderate severity of depression arising in the context of marital discord versus that in the context of a life-threatening illness may be handled somewhat differently in direct interventions, despite the basic similarity in some of the therapeutic strategies. Clinicians draw on their experiences to tailor make interventions/draw on components or approaches that are most suitable in view of the client's background factors, personality dispositions, specific vulnerabilities, content of stressors, etc., Although in unguided self-help programs, it is possible to direct users to appropriate kinds of materials and exercises based on initial responses provided to the intake questions that could be built into the program; the scope of individualization remains limited.

MANAGING MOTIVATION

In the context of unguided self-help apps, the issues related to motivation are 2-fold. First, motivation comes into play in the context of individuals making a decision to engage in self-care by utilizing internet-based resources. This step is likely to be influenced by (a) the characteristics associated with the potential users (e.g., access to internet, ease in use of internet, prior experience in seeking Internet-based resources, severity of the problem, etc.) as well as (b) the manner in which information about Internet-based self-help apps is disseminated to public. Even when apps with empirically demonstrated efficacy are made available for public consumption, their large-scale impact is influenced by their uptake by people who are most likely to benefit from the same. Improving uptake of self-help apps requires (a) efforts at providing comparative information about apps in ways that are user-friendly and guide individuals to make suitable choices (b) using principles of social marketing to reach out to potential users and enhance their motivation to engage in health promoting self-care behaviors.[14]

The second issue related to motivation management arises after an individual makes a decision to engage in self-help, chooses a self-help app, and starts using it. Unguided self-help programs rely solely on motivation of the users to go over the program content as well as to try and put in practice what is learnt.[4] Moreover, adapting general strategies in ways that are personally relevant requires cognitive efforts as well as a certain level of motivational readiness. Depletion of motivational resources due to mental health problems can interfere with sustaining self-care efforts. This again implies that such programs may be undertaken and completed only by a segment of individuals in the community who are able to mobilize internal and external resources that aid motivation. Various kinds of beliefs and cognitions may interfere with effective and timely utilization of self-help methods. For example, in case of depression, some of these barriers to utilize/apply self-help methods could include beliefs/thoughts such as “I cannot do a thing,” “it is all the fault of the situation/a person that I am feeling this way and that has to change first,” and “I am a helpless victim.” Although these are also likely to occur in face-to-face therapies, the involvement of the therapist is likely to help in dealing with them. In case of unguided self-help programs, these challenges may be addressed to an extent through building motivational enhancement components into the apps. Such elements could include content that involves direct coaching to enhance motivation, use of auto reminders/text messages, etc.

KNOWING WHEN TO STEP-UP

Yet another potential challenge or hazard associated with unguided self-help interventions is not making efforts to make the user aware of the limitations of self-care. Self-care approaches, particularly, unguided self-help approaches can be considered low-intensity interventions. Stepped care model entails guiding individuals to step-up to higher intensity interventions when required.[15] Unguided self-care programs need to build in elements that teach users to monitor indicators of severity over time and make appropriate choices at the right time to shift from self-care to other higher intensity interventions. Several studies indicate that individuals, especially youth may perceive self-help and peer support to be sufficient for dealing with common mental health issues or may overemphasize self-reliance[16] in ways that could act as barriers to professional help seeking (e.g., “I ought to always manage totally by myself,” “if I reach out for help, it means I have failed,” and “It is not acceptable that I have to ask others, especially professionals for help”). Addressing this issue in unguided Internet-based self-care programs requires complimentary utilization of strategies that enhance e-health literacy of potential users as well as sincere efforts to build in educative information in the apps, so as to help people understand the limits of self-help. Thus, the message that self-care intervention programs need to communicate is that self-help does not always mean doing things alone and that self-care continuum involves mobilizing external resources (including professional support) to help oneself, as and when needed.

Advantages

Despite the challenges enumerated above; unguided self-care programs can serve multiple functions in low-resource settings. These can help in reducing treatment gaps for common mental disorders by providing tools for reducing severity and maintaining/enhancing well-being through aiding recovery. These could also be a beneficial use of time that may be lost before professional care can be obtained or can be used after completion of face-to-face therapy sessions, for consolidation of therapy gains. On the whole, well-designed Internet-based unguided self-care programs can play an important role in empowering users through provision of clear and useful information and strengthening skills to deal with symptoms/take care of one's mental health and well-being.

Recommendations

We provide a few recommendations for addressing some of the challenges associated with unguided self-help apps for mental health. These are briefly enumerated below.

1. Content-related recommendations: mandatory inclusion of components in unguided self-help apps that (a) clearly inform users about the research basis for the content incorporated in the app or direct evidence-base for the app itself, whenever available, (b) provide explicit information about scope of use and limitations of the app and offer some form of initial screening to provide appropriate suggestion to a given user, (c) help users in motivation management to apply what is learnt, (d) offer crisis support strategies, and (e) offer assistance in making decisions to step-up to higher intensity interventions as and when required

2. Recommendations related to classification and appropriate uptake of mental health apps: We believe that it would be worthwhile to develop a classification system for unguided mental health self-help apps that can be utilized to aid lay public to make informed choices. This system could be developed through expert consensus and could utilize relevant features/components/functions that can serve as parameters for decision-making/choosing an app. Efforts at various levels would be required to actively reach out to the public to ensure optimum uptake of unguided self-help apps that have demonstrated their clinical utility. Mere availability of high-quality apps is unlikely to make a public health impact unless accompanied by a wide adoption by the target population.

The above two lines of efforts need to accompanied by efforts to enhance the literacy of the target population regarding Internet-based mental health programs, their utility, their limitations as well as ways to determine potential utility, etc.

CONCLUSION

Internet-based unguided self-help interventions for mental health problems pose several challenges for potential users such as choice of app, limited scope for contextualization, motivation management, and monitoring the need to step-up to a higher intensity intervention. However, these are not absolute challenges intrinsic to unguided self-help apps and it is possible to minimize risks and maximize gains for users through synergistic efforts by clinicians, researchers, policymakers, and public health experts while designing and disseminating such initiatives to address treatment gap in mental health.

Financial support and sponsorship

The authors gratefully acknowledge the funding support of the Indian Council of Medical Research for an ongoing research study on development and pilot testing of a self-help app on depression.

Conflicts of interest

There are no conflicts of interest.