Social Services Innovations: Evaluating Health Apps
By Melanie Sage, PhD, MSW, and Monaca Eaton, MSW
Social Work Today
Vol. 19 No. 2 P. 8

It’s no surprise, given our use of technology and smartphones, that people are turning to apps for self-help. Smartphone ownership in the United States has jumped from 35% to 75% in the past seven years, according to Pew Research. Americans check their phones nearly 80 times per day, equating to once every 12 minutes. According to a study by Hopelab Well Being Trust, 64% of teens and young adults say they use apps for health. In addition to offering on-demand services and support, reduced costs, and portability, smartphone apps feel familiar and may build on already developed habits and routines.

Apps help remove many practical barriers to accessing service, yet they are not without risk. Little is known about the efficacy of most health apps, which also lack regulation and oversight ascribed to most health aids. They claim to help with a variety of goals, ranging from self-management to assessment and treatment, but rarely help with connection to a licensed mental health provider. Whether your clients choose to use a health app on their own or with a recommendation, we must consider our duties to provide psychoeducation, operate within our scope of practice, and stay up to date on the latest tools.

Considerations for Use
Research2Guidance reports more than 300,000 health apps were available for download in 2017. The National Institute of Mental Health divided mental health apps into six categories to assist with planning and evaluation: self-management, cognition improvement, skills training, social support, symptom tracking, and passive collection. There are no formal guidelines within social work regarding the evaluation of apps, although the NASW Technology Standards and Code of Ethics make it clear that practitioners should have skills and knowledge related to any tools they are using as part of treatment. To begin, make sure that the addition of an app to your treatment plan serves as a support and not a distraction for the client. Do both you and the client have the skills to incorporate a specific app into treatment? How will the app support the treatment plan? What instructions will the client need to successfully use the app?

Evaluating Apps
The American Psychiatric Association offers a good model for evaluating apps. They suggest that clinicians first understand the basics: Who created the app? What are the costs (download fee, recurring costs, data usage) for the app, and how do these impact functionality? How easy is the app to use? What digital literacy skills will the user need?

Social workers should download and use the app before recommending it to others. Be mindful of the functions, successes, and frustrations of the use. User reviews may help in determining the strengths and weaknesses of the user experience, but shouldn’t be mistaken for clinical efficacy.

Understand the risks involved with using the app. What personal or sensitive information does the app retain; how is it stored and who has access to it? If there is data protection, how will app developers protect and secure them? Are data encrypted? How does data collection, storage, and sharing align with HIPAA and agency policy? Does the app have a privacy policy? Can you review or access collected data individually or with the client?

Apply your social work skills to analyze the claims of the app. What does the app claim to do? How will the services of the app support that claim? Become familiar with the methods the app will use to meet that claim. What informs the assessment or advice generated by the app? How does this align with evidence-based practice standards? How does it align with clinical standards and practice knowledge? Does it align with the values and ethics of the social work profession?

This line of assessment provides a high bar, but some apps have made the cut. For instance, the VA has apps that coach veterans through management of PTSD symptoms or help with sleep using evidence-based protocols. Their apps are typically meant for use in conjunction with a therapist, and are available free to download through app stores. In a 2018 research paper, “Veterans Affairs and the Department of Defense Mental Health Apps: A Systematic Literature Review,” authors collected the findings from about eight of 20 existing VA/Department of Defense apps, and found that they were widely acceptable to clients. Two had undergone research to demonstrate effectiveness: the Virtual Hope Chest, which offers tools for distraction, inspiration, relaxation, and coping, and the PTSD Coach, which provides tools for education, self-assessment, and symptom management.

Users can expect that government agencies such as the VA or Substance Abuse and Mental Health Services Administration develop apps in consultation with experts. However, a 2019 research review in Health Affairs by Savafi and colleagues titled “Top-Funded Digital Health Companies and Their Impact on High-Burden, High-Cost Conditions” found that the even the top-funded health apps usually pilot their tools with small samples of mostly healthy people, and have not demonstrated impact on cost-savings or health burden with the highest need populations.

Use Your Social Work Skills
The most helpful apps for social workers to use with clients may not be branded as mental health apps at all. For instance, we know from evidence-based interventions that food, sleep, and exercise can all have impacts on well-being. Tools such as Fitbit and Apple Watch have built-in monitoring for some of these categories. A social worker and client can review data together alongside a digital or paper mood log to talk about relationships between these things, thereby promoting insight and self-monitoring. A social worker can also encourage clients to use timers as medication reminders, compile a mobile song playlist that improves their mood or a digital photo album of pictures that make them happy, or create an easily accessible mobile safety plan. These ideas simply move tested analog tools to digital environments. Clients can test and report back about the impact of apps they already use, including digital coloring books, games, social media, or health apps, that may have negative, positive, neutral, or mixed impact on mood. It is important to evaluate the impact of tools with your clients over time.

Case Example
Simone is 21 and enjoys technology. You are her case manager, helping her cope with transition related to her prior history in which she was a victim of sex trafficking. She has anxiety and depression, and has found an app called Youper that says it uses artificial intelligence, and offers mood tracking, coaching, journaling opportunities, and self-evaluation.

Using the outline provided earlier, you see that the US-based app says its CEO is a psychiatrist and identifies him by name, and the app is free for now but may require payments in the future. It does not provide medical advice, and encourages use alongside therapy. Its privacy policy says it does not collect protected health information and does not sell encrypted user data. Data are stored in the cloud and not shared with other app users, but they may share deidentified aggregate data, according to the website. The lengthy terms of service say it complies with the General Data Protection Regulation and uses cookies to track activity. The app store contains 3,000 reviews, mostly with high positive marks. User critiques include log-in difficulties, that it is sometimes repetitive, and that it sometimes requires a response but does not offer multiple options. It does not purport any specific therapeutic model, but appears to use cognitive behavioral therapy–related strategies and evidence-informed self-evaluation tools. There is no live help. It collects e-mail, age, and gender for registration or use. It also says users can delete their own data, which removes them from all company databases. It does offer social sharing in which users can post mood information to apps such as Facebook and Twitter.

You download the app yourself to explore it so you can better talk to Simone about her about her experiences and assess whether it may be helpful to your other clients. You notice some features such as spoken meditations may not be accessible to clients who are deaf or hearing impaired, and extensive written prompts and journaling may be a poor fit for those who have trouble with reading or writing, but you do think of some clients who might benefit from the app alongside case management and therapy.

Given Simone’s professional supports and your app assessment, you encourage her to try it out but warn about the possibility of future costs, the risk that someone may be able to log in to her phone and access her journals, and the critiques shared by other users. She says she does not plan to use social sharing because she wants to keep her mental health information private. You agree to check in weekly to talk about how it is going, get her evaluation of whether the app is helpful, and look at some app data with her during session if she is comfortable.

Final Thoughts
Because of the time and resources necessary, many apps will never undergo rigorous research to test efficacy. Social workers, therefore, should equip themselves to make informed decisions about what kinds of apps may be beneficial, keep updated about risks and benefits of app use and when to recommend them, know what information to provide to clients about their own self-directed app use, and understand app innovation. Social work benefits conversations from micro to macro levels. For instance, pharmaceutical giant Otsuka, maker of Abilify, is currently developing a pill that encases a digital sensor to track medication adherence by app that has potential to improve care, but could also introduce access disparities, reduce self-determination, or otherwise impact treatment. Innovation introduces an increased need for social workers to make informed recommendations about clients’ technology use.

— Melanie Sage, PhD, MSW, is an assistant professor at University at Buffalo School of Social Work.

— Monaca Eaton, MSW, is the associate director for teaching and instruction at Michigan State University School of Social Work.

Resources
American Psychiatric Association App Evaluation Model: www.psychiatry.org/psychiatrists/practice/mental-health-apps/app-evaluation-model 

University at Buffalo School of Social Work Helping Apps for Practitioners and Educators blog: https://ubwp.buffalo.edu/happe