After the birth of her third child, Kristin Rulon took a birth-control shot that triggered a wave of depression and anxiety.
The 32-year-old suburban Kansas City, Missouri, mother and writer explored natural remedies before joining the millions of Americans who have turned to mobile-device apps that offer therapy via text messages.
A therapist from the BetterHelp app in early 2016 typically exchanged three to four daily texts with Rulon from morning to bedtime. The access was great, Rulon said, but the $28 weekly charge for unlimited texting not covered by health insurance became too expensive. And Rulon worried that texts could not convey everything she wanted to share.
“In the early stages when I was in a dark place, I couldn’t get the words out to explain what I was going through,” Rulon said. “Even though I’m a writer, I like that person-to- person contact, looking into each other’s eyes and feeling that actual connection.”.
Rulon is among millions of Americans, often younger adults, who have experimented with mobile apps as a preferred or complementary method of therapy.
But at a time when suicide rates are on the rise, experts question whether such mobile services are ready for mainstream use, citing a lack of clinical evidence that online platforms make a meaningful difference for people. Even worse, critics charge that some apps often overpromote and underdeliver for those with pressing mental health needs.
Dozens of technology companies have created apps and websites that market text, voice or video chat therapy for people seeking help with spells of depression, anxiety or other mental anguish. Other apps expand beyond therapy with tips and advice on meditation and mindfulness.
“The potential is there,” said psychiatrist John Torous, who directs the digital psychiatry division at Beth Israel Deaconess Medical Center, a Harvard Medical School teaching hospital. “The question is, what actually works? … This is a problem that’s been around since humanity has been around. In a matter of months, we are going to write some code, put it on a phone app and eradicate suicide?”.
One thing Torous and others don’t quibble with is the need for behavioral health options. Nearly one in five U.S. Adults had some form of mental illness in 2016, and almost half of those adults lacked access to routine treatment, according to the National Institute of Mental Health.
Young adults, in particular, lacked access to treatment: Only 35 percent of adults 18 to 25 get treatment for mental illness.
Underscoring the challenge, the deaths of fashion designer Kate Spade and celebrity chef Anthony Bourdain this month came as a Centers for Disease Control and Prevention report showed that suicide has climbed nearly 30 percent since 1999 and now claims about 45,000 lives every year.
Endorsed by celebrities
Tech companies buoyed by endorsements from figures such as Olympic gold medalist Michael Phelps have promoted apps as an accessible and cost-effective way to get round-the-clock therapy.
The apps take on many forms. Some serve as a platform and connect users via text chats with licensed therapists. Another company touts a robot therapist. One trains “active listeners” who communicate with customers.
The listeners can provide emotional support for users on topics such as anxiety, heartbreak and grief, but they are not allowed to give medical or psychological advice. They can refer a user to a licensed counselor.
Behind some of these therapy apps are thousands of licensed therapists or psychologists, or in some cases volunteers, who are taking their skills to the virtual realm. In that vein, it’s the mental health industry’s version of the ride-sharing companies such as Uber or Lyft, allowing therapists to earn income on the side.
Mobile app companies 7 Cups, Talkspace and BetterHelp require therapists be licensed in their state and can work only with clients within that same state. While 7 Cups’ roster includes 250,000 listeners and 165 licensed psychologists, apps such as Talkspace and BetterHelp claim nearly 2,000 therapists.
By the end of 2019, Talkspace plans to expand beyond chats and employ licensed psychiatrists who can prescribe to clients within their respective states.
“We want to be able to provide medication under Talkspace,” said Roni Frank, Talkspace co-founder.
Therapy apps have become more commonplace among a generation seeking comfort from their phone rather than through face-to-face interactions.
The app 7 Cups gets 2 million unique users each month, and 90 percent of those users are under 35, according to Lara Gregorio, head of health systems for 7 Cups.
Technology allows her company to “meet people where they’re at in the moment with the help they need,” she said.
Telemedicine goes more mainstream.
Others worry that a text chat may not capture nuance and nonverbal cues that inform licensed therapists and psychologists.
“Body language always puts words into context,” said Lynn Linde, a senior director for the Center for Counseling Practice, Policy and Research at the American Counseling Association. “How many times has anyone misread an email because the nuance of the context is lost?”.
That was a concern for the Missouri-based Rulon, who is considering developing an app herself based on a self-care checklist.
After trying BetterHelp for three months in early 2016, Rulon turned to a therapist in her community for weekly in-person sessions. She found the human contact reassuring, citing an instance when her therapist took her hand and explained her thoughts and feelings were normal for a busy mother of three children.
Her therapist also was a more affordable option because the sessions are covered by her health insurer.
Rulon complements her weekly therapy sessions with a meditation app, Headspace.
“The combination of both has been extremely helpful for me,” Rulon said.
‘People are suffering so much’
Los Angeles psychiatrist Judith Orloff has a lot of patients who also use apps including Headspace and Moodnotes to help them practice mindfulness or meditation, something she supports because many of her often high-powered clients have a hard time meditating on their own.
If it helps patients figure out “what to do with their anxiety when it comes up,” she said, “it’s a good thing.”.
Orloff starts to worry, however, that when patients turn to apps or websites, they don’t know anything about their therapist, and those therapists know little about the patient.
If patients find someone “they resonate with who doesn’t want to put them on medications too quickly,” that form of telehealth could work, she said, as long as it’s coupled with support groups and other resources, possibly even apps.
The most worrisome of all to Orloff are apps offering help for people experiencing suicide ideation or seeking anxiety release hypnosis. People who are suicidal need to have “immediate excellent attention or to be put in a psychiatric hospital, as they are a danger to themselves,” she said.
Anxiety release hypnosis outside of a therapist’s office could lead people into the “painful territory” of remembering trauma in their childhoods that prompts even more anxiety, she said.
There may be an app for everything, but that doesn’t mean they should be used for everything, especially mental health.
“Mental health can be so fragile,” said Orloff, author of six books, including The Empath’s Survival Guide. “People are suffering so much.”.
‘Bolder and bolder claims’
Others worry that consumers may not be able to properly evaluate information provided by the thousands of apps addressing mental health.
Torous, who chairs an American Psychiatric Association working group on apps, said he reviewed 18 published studies on apps measuring the effect on depression symptoms compared with a control group.
The collective evidence revealed a small effect on reducing depression, but the apps did not move the needle on the most important measure: reducing suicides. He is not aware of any app that has succeeded by that measure.
Torous said he worries people may be wooed by claims from app developers seeking to stand out in a crowded market. If consumers turn to apps in lieu of in-person therapy, that could be problematic, particularly for people in crisis.
“The barriers to entry are so low for these apps,” Torous said. “Sometimes people start with good intentions and ideas, realize how difficult it is and make bolder and bolder claims to stay relevant.”.
Still, app companies defend their services as serving a desperate need for the uninsured and others who don’t get what they need from the nation’s patchwork mental health system.
San Francisco-based Woebot, a mental health “chatbot” built on clinical and data science, gets 1 million texts a week from users in 130 countries, company officials said.
One “way we can improve mental health is to not be ignored,” said Athena Robinson, chief clinical officer of Woebot. “We need definitive attention. I hope some of our methodologies can provide that.”.
App developers have encountered limited regulatory oversight of federal agencies such as the Food and Drug Administration and the Federal Trade Commission.
When the apps are offering actual therapy, though, they must adhere to state laws that require health care providers to be licensed in the same states as the patient.
While the FDA regulates medical devices, the agency has a narrow definition of mobile phones that qualify as a medical device. And the app companies often have carefully worded terms of service agreements that aim to define their products and services.
Woebot requires users to agree to its terms of services before using the free device. Those terms describe the device as a “pure self-help program” that does not include medical care or mental health services.
The Federal Trade Commission has pursued actions against medical apps that violate a federal law prohibiting unfair and deceptive acts and practices.
In 2016, Lumos Labs, maker of the brain-training program Luminosity, agreed to pay $2 million to settle allegations that the company promoted “unfounded claims” that its games could help people perform better at work and school and delay age-related cognitive impairment.
But no FTC action has targeted an app offering therapy or other behavioral health service.
The federal agency offers a Web-based tool to inform mobile health app developers about rules and regulations that may apply.
App developers need to be careful about what they claim their app can do for the user, said Ellen Janos, an attorney and health law expert with Mintz Levin, a Massachusetts-based law firm with offices in D.C.
“They want to be bold and they want to advertise and promote their app,” Janos said. “But they need to do so in a responsible way. If they are making claims, they need to substantiate those claims.”.
Others expressed concerns about how the mental health apps safeguard users’ private information. Chat providers may disclose how they handle users’ health information, but unlike doctors, hospitals and health providers, no chat app has been fined under a federal law on patients health information.
“As a consumer, I would be a little concerned about that,” said Linde of the American Counseling Association.
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