The expanding use of mobile health technologies is “unprecedented in the history of medicine.”1 Apps have “transformed many aspects of clinical practice” because apps “provide many benefits for health care practitioners, perhaps most significantly increased access to point-of-care tools, which has been shown to support better clinical decision-making and improved patient outcomes.”2 Psychiatrists, clinical psychologists, psychotherapists, and other mental health clinicians are increasingly faced with questions regarding the efficacy and risks of mobile and online apps.2 The American Psychiatric Association (APA)’s Expert Panel on apps notes that apps can be “appropriate and useful” in the care of patients with psychiatric conditions but delineates several potential dangers in apps that mental health practitioners might be using in the course of their practice and highlights concerns and questions that practitioners should consider before using an app.2
One of the uses of an app in clinical practice—including the practice of psychiatrists—is to assist in the screening, diagnosis, and monitoring of depression.3 A study of physicians and patients found that both were interested in such an app and were seeking tools that would be “easy and intuitive” to use and would offer “personalized content.”4
To offer insight into such apps, we spoke with 2 experts involved in researching and developing apps to be used by psychiatrists and other physicians to screen for depression and diagnose and manage patients with the condition. The apps address different needs and use different technologies, but taken together, they shed light on the manifold ways that apps can be used for depression management in clinical practice.
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How did you develop the treatment approach used in your app?
Dr Shah: I teamed up with John Mann, MD, who is a professor of Translational Neuroscience and a former vice chair for research in the Department of Psychiatry at Columbia University. He is also the director of research and director of molecular imaging in the Neuropathology Division of the New York State Psychiatric Institute.
Dr Mann had written a review in the New England Journal containing a treatment algorithm for medical management of depression.10 Many psychiatrists regard the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study11 as a treatment algorithm, but although it was an instructive and helpful clinical trial to teach us about depression and medication, it is not necessarily the most optimal way to treat depression today.
How does your approach differ from that of the STAR*D?
Dr Shah: Here are a few examples. The STAR*D studied improvement in symptoms every 4 weeks, but we think the data suggest it is better to check for improvement every 2 weeks. The STAR*D suggest that if 1 selective serotonin reuptake inhibitor (SSRI) does not work, the patient should switch to another SSRI.11 In our treatment algorithm, if people do not improve on one SSRI, they can switch to a serotonin and norepinephrine reuptake inhibitor (SNRI).
What else does the app offer?
Dr Shah: The app offers clinical pearls for depression treatment in a stepwise fashion; titration protocols for the 7 essential generic medications used to treat depression; build-in calculators for the PHQ-9 and the Columbia Depression Scale Suicide Risk Assessment (C-SSRS), and safety planning.
The tool suggests “gateway” screening questions that, if the patient responds by saying “yes,” more formal tools are suggested. For example, if the patient indicates that they have needed much less sleep, it is recommended that the patient has a longer, more formal bipolar screening scale, which is also included in the app.
If a patient presents and you think they have depression, you can open the app. It will remind you of the diagnostic criteria for depression. You can select whether the patient is presenting for an initial or a follow-up visit. The app prompts you to ask important question about suicide risks as well as questions to see if the patient might have bipolar disorder rather than unipolar depression. When a medication is suggested, there is information about how to initiate and titrate the medication, the most common side effects, and the full FDA prescribing information if you want to do further reading about the medication.
The app will also help as the patient comes up for follow-up to ascertain if the patient is improving, has not changed, or is in remission, and will suggest options, based on those results. Should you change the medication? Change the dose? How soon should the patient be seen again? This tool can help you longitudinally in managing the patient.
It sounds a little like a “cookbook” approach. Where does clinical judgment fit into the picture?
Dr Shah: Even in the kitchen, you need to combine use of a cookbook with your own judgment. That’s certainly the case in a clinical setting. You are treating human beings and you are a trained clinician. No app can be applied in a robotic manner or replace clinical judgment. Rather, it is another tool in the toolkit and a way to help you incorporate the latest research into practice. No matter what algorithm we create, it can never recreate every scenario in humankind, but it is likely to cover much of what is seen in routine clinical practice. We expect clinicians to use their judgment, just as they would with any clinical tool.
And does information automatically get transferred to the patient’s electronic medical records (EMR)?
Dr Shah: The app is downloadable via the web onto a smartphone or computer and has exportable PDFs. We do not currently collect any data that is on your own computer or smartphone. We are in the process of developing a system of integrating the information with the patient’s EMR, and of course once we do that, any transmission mode will be HIPAA-compliant. In addition, we have an automatically generated text to document the clinician’s decision-making process and the clinician can add that to the patient’s notes.