Opinion Article by Jamie Prangnell, Managing Director, Appadoodle.Mental ill health is a huge issue for young people. It is estimated that one in five young people have a mental health problem in any given year. Further research says that around half of all mental disorders begin before the age of 15, and 75% by 24. More than half of all adults with mental health problems saw such issues manifest in childhood, but were not formally diagnosed.
With ever-increasing pressures on young people around education, work and home life, there is a sad inevitability that the issue needs addressing. Tools that enable prevention and early intervention are crucial on the road to recovery, especially for illnesses such as psychosis. And clinicians are seeing technology as an essential part of the solution, particularly as access to formal services will be very difficult as demand is likely to outstrip supply.
Many companies are working with the NHS on app development, and Appadoodle’s involvement has been with clinicians at Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT), one of the largest such trusts in the country. Early intervention in psychosis and other teams from BSMHFT wanted to look at new ways of engaging with young people, and apps were one such option.
Why apps?
The reasoning is convincing. Technology is becoming a crucial part in the diagnosis and treatment of mental health, especially for the young. As Max Birchwood, professor of youth mental health at the University of Warwick and a leading thinker in the field, noted at a recent mental health apps launch: "Half of most young people up to the age of 25 will experience some form of mental health issue. Getting help quickly and appropriately is crucial. We need to use youth-appropriate channels to give young people access to help, advice and interventions during a critical period when mental health problems develop."
As over 80% of 16 to 24 year olds own a smartphone, many using them for games and information gathering, it made sense to clinicians at BSMHFT that using apps would be an appropriate approach to diagnose and treat young people with mental health issues. Plus, as noted in the NHS Confederation's 2013 discussion paper, people are embracing technology to help them manage mental health issues as it can help with prevention and recovery, as well as address resource challenges within the NHS.
And the evidence for using apps as part of treatment is growing. A 2013 Australian study, for example, showed that mental health apps have the potential to be effective and may significantly improve treatment accessibility.
The NHS' technology vision, the Personalised Health and Care technology framework, points to reducing the need to use health and care services by using technology to help more people build up the knowledge, skills and capabilities they need to manage their own care and symptoms. This plan sets out support for low-cost high-efficacy apps, with a particular priority on mental health services.
Apps can help with address youth mental health issues
Working with clinicians at BSMHFT, including those involved in the trust’s highly-regarded YouthSpace mental health pathway for young people, Appadoodle has brought its experience working with young people and collaborated on a series of apps that look to achieve the aims outlined above. These help with young people’s treatment for and recovery from psychosis (Silver Linings), ADHD (Focus ADHD) and building emotional resilience. All are designed to encourage positive approaches to youth mental health.
Psychosis begins in adolescence and problems can escalate quickly, notes Professor Birchwood. Getting young people access to information and advice is important, and there can be a long delay between the onset of symptoms and treatment – up to a year in some cases. Delays can also occur once young people enter services, as they can find them stigmatising and youth-inappropriate. Apps can reach out to young people who are reluctant to engage with support.
With ADHD, the logic is similar. This developmental disorder also can begin in young age, and the nature of the problem surface in early adolescence. Apps using evidence-based interventions help to reduce stigma, and user-friendly channels can improve access to advice as soon possible.
Apps can also be designed to encourage young people build emotional resilience, which is another area we are exploring. Resilience is the capacity of individuals to bounce back from adversity. Building emotional resilience is thought to be an important preventative tool for people from vulnerable backgrounds, and young people who are resilient can help prevent mental health issues arising later in life.
The apps Appadoodle has developed are all part of early awareness and engagement for young people that aim to help prevent problems from getting worse, and support ongoing interventions that are being deployed in mental health services.
The potential for the Silver Lings app is outlined by Dr Erin Turner, consultant psychiatrist from the early intervention service at BSMHFT: "From a patient perspective the app will help them to understand and manage their illness, and empower them on their road to recovery. From a clinical perspective, it helps us know patients are involved in managing their own recovery, and can give us longitudinal information that helps us to tailor our treatment plans."
Designing apps that have the most chance of success
Young people's engagement with a course of treatment is another issue that apps can help with, and this is where gamification can help, as we have seen with our work with young people on other apps and digital developments.
Gamification takes elements of game design such as badges, and levels, and uses them to encourage engagement and particular behaviours. Gamification should make it simple for patients to achieve certain treatment objectives, such as understanding triggers for particular episodes.
We applied gamification with Silver Linings and the Focus ADHD apps, where achievements include filling out the mood diary, plus a set of milestones, which unlock badges as rewards according to a personalised avatar.
Such techniques complement the goals agreed between the clinician and the patient, plus there is growing evidence for their effectiveness. A Canadian study of the Pain Squad app, aimed at adolescents with cancers, showed that the game-based nature of the app was appealing to adolescents, and could be seen to have helped with high compliance rates.
Co-design with young people is another crucial aspect of app development. By talking to clinicians and involving end users, apps can be designed to work in ways that encourage greater use as part of treatment.
Such design approaches are novel for healthcare, but increasingly promising. A US study found that involving end users in development, and working with technology and healthcare experts, may result in apps that maintain engagement and impact self-management and health outcomes.
The success of health apps in the mental health field will require young people to engage with them and use them. There is a growing evidence base that the Internet and apps are an effective medium for delivering evidence-based interventions such as cognitive behavioural therapy (CBT). Whilst Appadoodle plans to work with academic and other partners to evaluate and promote the effectiveness of all the apps, we - in common with everyone involved in the field - need to keep listening to end users and clinicians about how we can help realise the vision of mHealth for mental health.
Appadoodle has experience working with applications that interface between mobile and web solutions, which provide NHS, or other healthcare providers with the ability to pass patient information securely, or anonymously. This can be reported into a secure web panel to help inform healthcare research, or provide clinicians with real-time data about their patient's treatment and recovery.