Evaluating e-health promotive solutions for depression?

Authors: Daiga Garsila, Nursing student at Arcada-University of Applied Sciences (daiga.darsila@arcada.fi), Valentina Pontellato, Nursing student at Arcada-University of Applied Sciences (pontellato.valentina@arcada.fi), Kristine Refina Nursing student at Arcada-University of Applied Sciences (refinakr@arcada.fi), Josefina Sundman, Nursing student at Arcada- University of Applied Sciences (josefina.sundman@arcada.fi)

Introduction
Depression is common but often an unrecognized illness and a substantial cause for disability- retirement in Finland alongside with musculoskeletal disorders (Tiihonen, Tanskanen, Hoti, Vattulainen, Taipale, Mehtälä, & Lähteenvuo, 2017). One in ten people live with chronic depression in Finland (Ibid., OECD, 2017). Challenging attitudes from patients, discrepancies in communication may result in misdiagnosing and treatment delays amongst mentally ill patients (Shefer, Henderson, Howard, Murray & Thornicroft, 2014). Finding the right treatment is demanding, as the condition may co-exist with other comorbidities and the patient´s unique background needs to be considered (Mahan, 2005). So far, the official treatment for depression has been identified as a combination of medication and psychotherapy (Van der Auwera, Schomerus, Baumeister, Matschinger, & Angermeyer, 2017). In this text, we have collected and tested different mental health apps, with focus on apps for treating depression. Hence, the app Happify has been chosen and analyzed in depth and critically evaluated. The purpose is to understand whether this app is effective in supporting users with depression and a valid alternative to normal psychotherapy. As a frame for our discussion and evaluation we are using the work of Boudreaux, Waring, Hayes, Sadasivam, Mullen and Pagoto (2014) in which they present criteria for evaluating health promoted apps and digital solutions.

Digital solutions for e-health
Several digital solutions attempting to help depressed consumers have been brought to the market in these recent years. Here is a short descroiptions of the four apps

Kry
This is a Swedish app that has more than 200 accessible doctors allowing patients to contact them through video call and get help with health issues which do not require physical examination. Doctors can refer or do sampling, issue medical certificate, and prescribe and renew medications (Kry, 2018).

Worry Time
People with depression often have a history of anxiety disorder (ADAA, 2018). Worry Time allows consumers to write and monitor their daily anxieties that may hinder their functionality. The app will repeatedly remind them to worry based on their selected time until they can focus and shift their emotional responses. As a result, it is easier to go on with daily duties without constantly worrying. In time, the list can be shortened and writing down the troubles can make one consider if it’s worth worrying about it or is it irrational or simply out of self-power to control (ReachOut Australia, 2018).

Meru Health
Meru Health focuses on continuous therapy for clinically diagnosed depressed patients for 8 weeks. It is accessible once a patient received a referral from a licensed healthcare professional. The app features an 8-week mindfulness meditation and therapies such as cognitive and behavioral. Managing stress was the core component of the application as their initial motive until it was then developed as digital intervention for depression. (Meru Health, 2018).

Happify
Happify provides behavioral change solutions for private users and corporates in addressing different emotional and psychological challenges such as anxiety, depressive symptoms and stress. The collaboration between a team of scientists, health-care clinicians and gaming experts led to a platform that uses games to help people achieve a better emotional well-being as its primary goal is to make people feel happier (Happify, 2018).

Evaluation of the app Happify
According to the Happify´s website, there are currently over 3 million users that are engaged in using the app and more than half of the users feel an improvement within two months. Despite its initial popularity, what makes Happify enticing to the users? Essential question for all health promoted apps (Boudreaux et al 2014). The blending of gaming, science and technology creates personalized experiences which increase the level of engagement. The users experience is firmly rooted in integrating the best of engagement technology to make the experience fun and pleasant. Many activities in Happify are organized according to the STAGE categories: savor, thank, aspire, give and empathize. However, a free play section is also available for the ones who prefer picking their activities themselves (Carpenter et al. 2016). Furthermore, users are encouraged to engage in real-world activities off the application´s interface (Bakker et al. 2016) by being asked to try a certain new behavior in their everyday life and then report about it (Carpenter et al. 2016). Happify largely employs the concept of gamification: engaging and motivating people by using game-like mechanisms and thinking (Kapp, referred in Bakker et al. 2016). Apparently, games-like activities are more likely to engage individuals in challenging tasks (Harter, referred in Bakker et al. 2016,).

Depression reduces the size of certain regions of the brain and decreases the number of synapses (Duman and Aghajanian, 2012). Since these regions also control emotions, mood and cognition, curing depression is no easy task. The creators of Happify believe the brain can be thought new patterns through regular exercise in order to overcome negative feelings. Most of the depressive and negative thoughts are irrational, such as assuming the worst and looking/reacting to circumstances in a negative and unhealthy way. It encourages a deeper look into the little things that could be taken for granted. For instance, practicing gratitude by reflecting on success and being thankful can revoke positive emotions and lead to expression of more compassion and kindness and make one feel more alive (Carpenter, 2018).

It should be clear to the consumers that Happify is a purchase required application. The developers´ aim is ultimately to profit, so the motive behind is obviously financial (Sullivan, 2013). The app needs more users in order to profit as well as the current users to want to keep using it. Although, purchasing the application in the first place assumes that users has self-diagnosed before making the decision of “treatment”. Also, there could be other causes for their state of mind for which application could not help to identify. A physiological condition could be missed and assumed to be psychiatric one (Pillay, 2010).

In 2014, the New York Times described Happify as “perhaps the most sophisticated positive vibes app available now” (Morais, 2014). However, evaluating a mental health app is very challenging. It is hard to rigorously classify applications in general and no standards are available. The are no widely established rules or checklists on how to choose one as well as no randomized effectiveness control. Therefore, judgment is often left on the hands of the consumers (NIMH, 2018).

Discussion
It is still unclear whether digital apps can truly support mentally ill people. However, some studies show that for common disorders such as anxiety and mild depression there seem to be no valid evidence of online-based treatment being less effective than the orthodox face-to-face therapy (Cuijpers, cited in Rosenberg, 2015). Yet, scientists are divided. Can human interaction truly be replaced? Can an application like Happify enable us to take control over our depressive thoughts? Being able to regulate our emotional life entirely by ourselves sounds rather challenging. As Hertenstein (2015) points out we have “stone-aged minds” which still rely on body-language and facial expressions to interpret others’ emotions. From our understanding of Happify, the focus is mainly on the individual. Maybe this is no surprise, given that the areas of development for apps focus a lot on self-oriented training, for instance self- management and skill-training apps (Boudreaux et al 2014; NIMH, 2017). Perhaps this is also related to our modern culture, which increasingly promotes instant gratification and quick relief. On the other hand, depression and psychological pain often emerge in response to difficult human relations or a traumatic past and, therefore, as Atlas (2005) suggests they require a human relationship to heal. Happify lacks elements of CBT (Cognitive Behavioral Therapy) which is commonly used in high-intensity intervention for depression (University College London, cited in Stawarz et al. 2018). Features focus mostly on mood tracking, dealing with negative thoughts, mindfulness, self-assessment and relaxation techniques. CBT is not mentioned in Happify, so it is not misleading for users as in the case of other applications which mention CBT without in fact providing it (Stawarz et al. 2018).

Furthermore, Happify requires its users to be committed and to engage regularly. People with depression, however, often struggle with weak cognitive abilities which lead to problems with concentration, memory and decision making (Ainsworth, 2000). For that reason, an application such as Happify could be a good support, but not a substitution, to the therapy for people who struggle with any form of depressive disorders, since they may not be able to consistently gain benefits out of it.

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