Mental health disorders are the 'single largest cause of disability in the UK', said life science minister George Freeman when he announced the creation of a £650,000 prize fund to develop new mental health apps. Using technology to support greater self-care is a key part of the NHS' digital vision for both physical and mental health. Apps are central to this ambition; they can deliver personalised care in the palm of your hand, and their potential for use in mental health is fast becoming recognised.
But this technology does not replace the need for face-to-face clinical care; a fact that is clear to the young people who are now trialling Silver Linings, an app that supports young psychosis service users at Birmingham and Solihull Mental Health NHS Foundation Trust, and which has been developed with app developers Appadoodle.
Key features include the ability for the user to track medication, mood and well-being, access well-developed content to help understand their condition, and build coping strategies as a result. This helps young people keep on the road to recovery, even in between appointments.
"The app is an extra tool that I use as part of my treatment," says Joe, a service user with the early intervention service (EIS) at the trust. Joe uses Silver Linings to record how he is feeling every day, so that he can then share this with his doctor to show he has been coping over a period of time.
"When I wasn’t using the app, I would try to write things down, but often forget to do so, especially if I had had a bad week. But I find it easier to record whether I am feeling anxious, or how I was getting on with new medication, using the app. The doctor can then review this at my next appointment, and update my care plan."
A powerful clinical application
Using the technology as part of treatment was an important part of the thinking behind the app. Dr Erin Turner, consultant psychiatrist in the EIS team, was a driving force behind the app’s creation. She noted how the app can help patients that use the service understand and manage their illness, and empower them on their road to recovery. For clinicians, it can provide additional insight into how they can best treat the individual.
"From a clinical perspective, it helps us know patients are involved in managing their own recovery, and can give us information that helps us to tailor our treatment plans."
Much of the information that doctors need to tailor those plans comes through talking to the patient. With an app, the human element is absent. Appadoodle used some of the latest design techniques, alongside an appreciation of the needs of both user and clinician, to create an app that become part of a patient's everyday life as well as an important part of care.
"We had to overcome various challenges to interpret user input and translate this into something useful for users and clinicians," said Jamie Prangnell, managing director of Appadoodle.
"For example, the app's dashboard displays a range of information entered by the patient, such as their mood, whether they have taken their medication, sleep patterns and so on. By using a customised graph display, the user can see all their responses at once, or select a handful to see if there is any correlation, such as if a dip in mood followed missing medication.
"We also built a number of algorithms to provide supporting advice based on what the patient entered. So if the user says their sleep has been 'rubbish', they get advice specific to their needs, drawn for the well-respected YouthSpace website. If their sleep was just ‘bad’, the advice differs.
"If patients do give a negative response, they are prompted to give the reason why. And by using dropdown options for the user, we translated these responses into visual elements such as pie charts that clinicians can quickly understand," Prangnell added.
Gamification supporting clinically driven goals
Setting goals is another important of those treatment plans, and this is where Appadoodle brought their experience of working with young people and technology to the fore. The firm could see how gamification - the art and science of applying game-like badges and rewards - could support clinically-driven goals. By working with doctors and patients, they designed a user experience that worked for both.
"Gamification should make it simple for patients to achieve certain treatment objectives, such as understanding triggers for particular episodes. We created an entire gamification engine for the Silver Linings app. New users are assigned a personalised avatar. They unlock new levels as they progress through the app, and earn a reward when they level up or unlock an achievement, such as undertaking some exercise," said Prangnell.
Such techniques complement the goals agreed between the clinician and the patient. And whilst the use of gamification in health is still in relative infancy, 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 could be seen to have helped with high treatment compliance rates.
Maintaining patient engagement is an important part of care; if you stop taking the medication, you may well have less chance of recovery. Anything that can help will be welcomed, and gamified apps are certainly a step in the right direction, as is the use of excellent app design approaches.
The app uses Google’s material design principles and Android's Lollipop operating system to ensure that effective design is applied to innovative technology. One example of this is the use of a card view, in which the advice given to patients is presented as a card for the user to swipe away once read. This in turn helps to encourage greater engagement. Another is the use of alerts and notifications, so that patients get reminders when to take medication even when the app is not running.
"Being able to offer patients information and help in a 'user friendly' medium should help young people engage with their care, as well as enhance the therapeutic relationship," said Dr Turner.
mHealth set to grow
Turner recognises the potential for technology in the treatment of mental health, as did the NHS Confed in a seminal 2013 discussion paper. This extolled the potential for technology to help people manage mental health issues, and to aid with prevention and recovery, as well as address resource challenges within the NHS.
Technology is destined to become an important part of care for youth mental health, where early intervention and prevention is essential. It is thought 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. Many adults with mental health problems saw such issues manifest in childhood, but were not formally diagnosed, let alone treated.
So with mobile phones in use among around 80% of 16 to 24 year olds, and mobile game use soaring, a well-designed, gamified app is a sensible approach.
The trust is now prescribing Silver Linings as a core part of patient treatment, and is now working with Appadoodle on an app for attention deficit hyperactivity disorder (ADHD). This takes many of the principles and innovations of Silver Linings and applies it to a condition that is the most common behavioural disorder in the UK.
The technology firm is also developing app to help young people with building emotional resilience that could help those in most need to build the self esteem and coping strategies they need to deal with a society that puts ever increasing demands on the young.
The NHS has had a difficult relationship with technology - most notably the troubled National Programme for IT, which cost around £10 billion but failed to deliver the digital infrastructure required for modern healthcare. But there is renewed vigour for the use of technology in the NHS, and the use of apps in the treatment of young people’ mental health is showing the way.
About Appadoodle
Appadoodle is an award winning app and new media development company specialising in the healthcare and education sectors. The team has experience in creating apps that are engaging and fun to use. Utilising gamification is key to keeping interest of the user ensuring long term commitment to usage. Appadoodle is part of Walpole Media Group, a group of companies which work with young people in a range of ways.