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Despite what many public health experts might advise, some colleges are set to open in person soon and with that comes a new round of mental health needs in an already taxed student population. Prior to the pandemic, college students had high and increasing rates of depression and suicidal ideation, and a nearly two-thirds increase in diagnosed mental health conditions (22% to 36%) from 2007 to 2017. According to Dr. Victor Schwartz, Chief Medical Officer at The Jed Foundation and Clinical Associate Professor of Psychiatry at NYU School of Medicine, there are many reasons for these increases. He says, “Some of this reflects societal and economic stresses and more openness of many college admission processes, along with a reduction in stigma and progress in efforts to get teens and young adults to be more open to asking for mental health care and support.”
Whatever the reasons, Dr. Schwartz explains that “services and staffing in many centers have grown, but are not keeping up with demand.” In fact, between 2009 and 2015, counseling center utilization increased on average by 30-40% per school, while school enrollment increased by only 5%. This has led to waitlists, even though, as Dr. Ellen Fitzsimmons-Craft, Assistant Professor of Psychiatry at Washington University School of Medicine and Psychologist notes, “intervening in a timely manner is crucial [given that] three quarters of lifetime mental disorders emerge by age 24, with lasting effects on students’ health, social, educational, and economic outcomes.” To put it simply, college mental health was in crisis long before the pandemic and it is hard to imagine college health centers can handle what is to come when they open their doors in just a few short weeks. If the recent Centers for Disease Control and Prevention (CDC) data suggesting a significant increase in suicidal ideation over Covid-19 in this population (25.5% contemplating suicide in the last month) is an indicator of need, they likely can’t. Jessica Dyer, LCSW and Director of WashU Cares at Washington University in St. Louis adds that while colleges are uncertain how Covid-19 will exactly impact student’s mental health, with the added stressors of financial hardship, potential lost loved ones to Covid-19, and social isolation, among others, they are “bracing for the tidal wave of the impact.”
Students waiting for help are likely to be directed off-campus for care and also to the campus website for mobile apps to help with their stress, anxiety, and depression in the interim. The issue is, however, that most of their app recommendations are not good ones. That is at least according to a new study in the journal Psychiatric Services by Jennifer Melcher and Dr. John Torous from the Division of Digital Psychiatry at the Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School. In their research, they looked at the top 30 schools according to the US News and World Report’s 2020 rankings for “National Liberal Arts Colleges” and “Best National Universities,” and, for each of the 60 schools, they visited the counseling center’s website looking for any reference to apps as resources for students. They then coded each app for whether it was available, had been updated, had privacy policies, had efficacy studies, and whether it was paid or free.
This means that while they wait, students must become app experts on their own. Here are 5 things they should keep in mind when choosing a mental health app:
1) There is no “best app”:
It can be very tempting to pick an app to use by just looking up lists of best apps online, but according to Dr. Torous, the senior author of the paper, “There is no one ‘best’ app just as there is no one ‘best’ medication or therapy for every person….It is important to make an informed decision based on your unique needs.”
Without a list and colleges using outdated recommendations or not actually pre-screening them, searching can still feel very overwhelming. This is especially true as the landscape changes so frequently. A study showed that within 4 months, 50% of the search results of health and wellness apps had changed. To help potential users, Dr. Torous’s team created a database of apps that you can search by criteria that matter to you. You can also use the American Psychiatric Association’s library to learn about how to better evaluate apps using their 5-step criteria. Either way, as Dr. Schwartz adds, when it comes to apps “there is not a one sized fits all” and explains that he feels for them to be effective the “user has to find something that feels helpful for them.”
2) The technology matters:
It is really important that apps work and are updated. Just like you would want research to stay up-to-date and to be the highest quality, apps should be held to the same standard. A study showed they decline in quality after 6 months without an update. Dr. Sherry Pagoto, Clinical Psychologist and Director of the UConn Center for mHealth and Social Media, explains that it is actually a danger of the app if it does not work. She emphasizes, “That might not seem like a big risk, but if someone decides to download an ineffective app instead of seeking care, this is a lost opportunity to make progress on whatever the issue is as well as risk the problem worsens without effective care. The even worse danger is that an untested app has unintended consequences that make the problem worse.” Drew Perkoski, a Junior at Washington University in St. Louis, adds “When I look at an app my concerns are mainly who made it and who is using it. I would not want to beta test something that is supposed to help me manage my mental health.”
Functionality is also really important and whether it is easy to use will affect whether a student finds it useful. Dr. Fitzsimmons-Craft explains students have high expectations of their technology from daily use of apps like twitter, and while mental health apps might not be as “flashy,” they “have to work well and be easy for the student to use.” She feels that if they do not, “that evidence-based content is just not going to get through.”
3) The evidence base is important to know:
Many apps are not evidence-based and can be dangerous by making “unfounded” medical claims or offering dangerous or incorrect information, according to Dr. Torous. On the other hand, some apps have been rigorously tested as if they were a medicine and evidence for their efficacy submitted to the FDA for approval (which, interestingly, had their entry requirements for apps for mental health eased during Covid-19). Though still rare, FDA approval is important as it signifies a particular app is safety and efficacious for a specific problem, therapy, or disease. As a user, knowing the evidence for an app is important, and though not all of them might need evidence behind them (keeping a diary of medication taking, for example), it helps better weigh the risk of use. More often than not, however, as Dr. Torous points out “the app is just wasting the user’s time and offering them effectively no-care when that person could have been receiving actual help.” This same sentiment is argued by Perkoski who worries that the “trend” of mental health makes the loudest apps, the ones that might not be the best, sometimes the most appealing. He says it is important to know which apps are meant to “to connect you with real personalized care, and which are kind of algorithmic responses to fairly standard human experiences…[In other words,] a student should not be expecting more out of an app when it really just provides a daily horoscope wrapped in a Psych 101 textbook.” When asked for good examples of apps, Dr. Torous points to the Veteran’s Affairs apps as having good evidence and Dr. Pagoto points to Dr. David Mohr’s mobile apps Intellicare, which are based on cognitive behavior therapy.
4) Privacy is Key:
Given what just was released about Talkspace, privacy concerns are very important to weigh, especially when considering inputting your own clinical data into a mental health app. As it stands, many apps share or sell data and this often is unexpected to people. Dr. Schwartz says, “If data is being mined by an app and the student is not aware-as frequently occurs, the student might be surprised and troubled.” It is important to look to see if there is a privacy statement, what it says about collecting personal data, if it is stored or deleted, and if that data is shared with outside parties. Perkoski adds that he did work for a mental health technology company and he left because of the requests he was getting to do things that he thought were “borderline unethical.” From it, he learned to be “extremely cautious about the source of the applications you choose to download.”
5) Apps are a supplement to therapy, not a replacement:
All of the experts interviewed felt apps served a purpose in mental health treatment, but were not a replacement for traditional methods of treatment like therapy or medication. Dr. Torous says “right now apps cannot replace face-to-face care (be that in person or on the screen), but they can help augment and extend care to make treatment more personalized and effective.” He says that he has used apps in conjunction with regular treatment in his clinic and found good success. Dyer adds, “From research we know that the therapeutic relationship has the greatest impact on progress in treatment and I am not sure you can mimic that in a way that would replace human contact. I think the perfect use [of apps] is self-help [and] behavioral change in addition to a therapist.”
Ultimately, however, especially after Covid-19, one thing is clear, as Dr. Fitzsimmons-Craft points out, “Colleges simply can’t keep up with the demand for mental health services with in-person options alone – it’s just not possible.” As a result, apps need to be one part of the plan, even something to use as students who are not in crisis, wait for care. But, to be sure they do not do more harm, they must be systematically and thoroughly reviewed before use.