A Review of Current Digital Mental Health Care Applications for Anxiety Symptoms and Future Prospects

Article information

Psychiatry Investig. 2024;21(6):551-560

Publication date (electronic) : 2024 June 24

doi : https://doi.org/10.30773/pi.2023.0339

Hyerim Kwon¹, In Young Choi², Dai-Jin Kim¹, Jae Hyun Yoo^,1

¹Department of Psychiatry, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

²Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

Correspondence: Jae Hyun Yoo, MD, PhD Department of Psychiatry, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea Tel: +82-2-2258-6773, Fax: +82-2-594-3870, E-mail: jayyoo84@gmail.com

Received 2023 September 28; Revised 2024 February 26; Accepted 2024 April 9.

Abstract

INTRODUCTION

With the coronavirus disease-2019 (COVID-19) affecting the lives of hundreds of millions of people around the world in just 2 years, the need for efficiency in medical services became more urgent than ever. Information and communication technology model in medical services has been proposed as a novel alternative to match the increasing demand. In particular, the development and commercialization of 5G communication network technology has become the basis for digital transformation and expansion of medical services. People have experienced the convenience and usefulness of digital non-face-to-face medical services and health-related services during the COVID-19 pandemic. Unlike the existing medical system which focuses on patient treatment and follow-up care, it provides personalized medical care from treatment to disease prevention, based on each patient’s characteristics [1].

Digital therapeutics (DTx), a major part of the digital medical service, is emerging as a new paradigm in the medical industry. DTx refers to software medical devices that provide evidence-based therapeutic interventions to prevent, manage, and treat medical disorders or diseases and comes in the form of mobile applications, virtual reality (VR), games, web services, chatbots, and artificial intelligence [2]. As with conventional medicine, DTx goes through the process of verifying treatment efficacy and safety evaluation through clinical trials, approval by regulatory authorities, prescriptions by doctors, and application of insurance. It has several advantages such as low toxicity or side effects, low cost, easy monitoring of patient medication and condition, and easy collection, management, and customization of patient data, which is why it is drawing attention as a ‘third-generation new drug’ [3].

The digital treatment market is rapidly growing worldwide along with digitalization of medical care. According to the report, the global DTx market has grown from $2.7 billion in 2020 to $3.23 billion in 2021 and it is expected to grow at an average annual rate of 20.5% from $3.88 billion in 2022 to reach $17.34 billion in 2030 [4]. This average annual growth rate greatly exceeds that of the general pharmaceutical market, and Korea’s DTx market is expected to grow from $47.42 million in 2020 to $204.37 million in 2027 at an average annual growth rate of 23.2% [5].

Clinical trials are being actively conducted for DTx, especially in the field of mental and chronic diseases. The mental illness field has conducted the most clinical trials of DTx in the world over the past five years [4]. Currently, DTx are being actively developed for mental disorders such as depression and anxiety disorder, post-traumatic stress disorder (PTSD), schizophrenia, dementia, and attention-deficit/hyperactivity disorder. Although there are difficulties due to complex regulations and lack of policy support, as of October 2022 in Korea, five DTx are reaching the final phase of clinical trials governed by the Ministry of Food and Drug Safety.

According to the Mental Health Survey of the Korean Ministry of Health and Welfare, among major mental disorders, anxiety disorder has the highest lifetime prevalence rate after alcohol and nicotine use disorder and has the highest one-year prevalence rate [6]. According to the first ‘COVID-19 National Mental Health Status Survey’ after social distancing was lifted in the second quarter of 2022, mental health indicators such as depression and anxiety were more than five times higher (17%) than in 2019. Reduced income and isolation resulted in the steep increase of the rate of suicidal ideation up to three times higher than before the outbreak of COVID-19 [7]. In this context, the spread of remote medical care via DTx would be effective for those who are in the blind spots of the healthcare system.

DTx has shown promise in treating mental health disorders. However, more research is needed to fully understand their effectiveness and how they compare to traditional treatments. Some studies have found that DTx can be effective in improving outcomes, such as reducing symptoms, improving patient adherence to treatment, and decreasing healthcare costs. For example, ‘Sleepio,’ which is a cognitive-behavioral therapy (CBT)-based therapy for insomnia by Big Health, has been well verified for its effectiveness in relieving insomnia and improving quality of life and depression related to insomnia based on numerous clinical studies over the past few years [8,9]. Its large-scale (n=1,711) randomized trial conducted in 2015 confirmed that it improved both daytime and nighttime aspects of insomnia. In the case of ‘Somryst,’ which is ‘Pear Therapeutics’ digital treatment for insomnia, a study has shown that participants who completed all six modules of CBT significantly improved their insomnia compared to those who did not, and the efficacy was sustained at 12-month follow up [10,11].

In this review paper, digital health care applications, the most widely used among various DTx modalities, will be reviewed and discussed. The paper will review mobile mental health care applications developed for the treatment of anxiety symptoms, their key constituents, treatment goals, mechanisms of treatment, and future development directions will be discussed. As most of the currently developed applications are from the US and Europe and only a few domestic ones exist, this paper would like to propose ways for expanding the development of Korean DTx for anxiety disorder.

METHODS

There are about 20,000 mental health management applications developed so far [12]. Among them, ‘Calm’ and ‘Headspace,’ applications focused on meditation and mindfulness, are the most downloaded and popular [13]. Research has shown that mental health applications have distinct clinical benefits for users, with a meta-analysis synthesizing the effectiveness of more than twenty mental health applications suggesting that using applications to relieve symptoms and self-manage illness effectively reduced depressive symptoms [14]. When the application was combined with face-to-face or internet-based therapy, the effect was even greater [15].

The criteria for classifying anxiety symptoms treatment applications include target group, main goal, duration, form, cost, and medical device status, etc. (Table 1). For the review of anxiety symptoms treatment applications, related search terms such as ‘anxiety (disorder)’ and ‘panic (disorder)’ were searched in the Google Play Store. From the search results, six representative applications, most of which have over 4-star ratings and 1 million downloads (as of March 2023) were selected, and their major functions, concepts, and other features were reviewed. The number of domestic (Korean) applications was very small, so two applications with relatively large downloads were selected and reviewed. The reviewed applications with English language are ‘Calm,’ ‘Headspace,’ ‘MindDoc,’ ‘Rootd,’ ‘MindShift CBT,’ and ‘Youper,’ and the ones with Korean language are ‘Kokkiri’ and ‘Maeum Program’ (Table 2). For information on the efficacy of the applications, if available, the review of clinical studies and published clinical trials of each application is provided through searching Pubmed and clinicaltrials.gov. If an application has no evidence and no ongoing trial, the absence of evidence is also mentioned.

Table 1.

Criteria for classifying digital mental health care applications for anxiety symptoms

Table 2.

Summary of applications and their features

RESULTS

English language applications for treating anxiety symptoms

Calm

Calm’s major features on meditation and mindfulness are meditation with experienced experts, practicing mindfulness in daily life and learning ways to reach quiet thoughts (Table 2). The topics of mindfulness include deep sleep, soothing control, focusing, habit change etc. Sleep management features include relaxing stories, relaxation music, and soundscape for adults and children. Features of anxiety relief include managing and relaxing stress with daily meditation and breathing exercises, reducing anxiety with daily 10-minute programs (Daily Calm, Daily Trip, etc.), personal growth and addressing social anxiety through inspiring stories, and daily move programs for relaxing the body.

Calm also has other characteristics such as check-ins and reminders (four check-in categories: mood, gratitude, daily calm, and sleep). It presents inspiring quotes or program recommendations after each check-in. In the ‘Discover’ tab, one can search programs by title/narrator/artist/topic, and search by meditation time and goal as well. In the ‘Profile’ tab, users can check their dashboard, library, history, and check-ins. In addition, mental health trackers are available through ‘Daily Streaks and Mindful Minutes’ and there is a 7-day/21-day mindfulness program for beginners and advanced people. The natural sounds and scenes of ‘Soundscape’ are designed to help balancing mind and body, and there are mental health coaches to help breathing exercises. New music from top artists is added every week.

A study of Calm (2019) involved 88 college students and found that after eight weeks of use of Calm ten minutes per day (with adherence of 54% weekly), there were significant improvements in stress, mindfulness, and self-compassion compared to the control group (Table 3) [16].

Table 3.

Studies on the efficacy of the applications, including randomized controlled trials (RCTs)

Headspace

Headspace’s daily meditation involves guided meditation and mindfulness exercises, personalized recommendations based on one’s activity, daily training with a new topic each day and a 3-minute quick mental reset. One can learn meditation techniques and find answers to mindfulness questions and start a day with ‘The Wake Up’ which is a short daily video series. Sleep sounds and meditation involves creating conditions for comfortable and peaceful sleep, ‘sleepcasts’ with calming narration and relaxing sounds, natural ambient sound recordings, and calming sleep music for deep sleep. Anxiety relief and adapting meditation program includes relieving stress through ‘SOS’ sessions in anxious moments, breathing training, building resilience with the ‘Weathering the Storm’ collection, and meditation to cope with sadness/anger and adapt to change. For focus and productivity improvements, Headspace provides programs such as curated playlists to improve focus for working from home, focus-enhancing music to set a good mood for the day. For core body training, one can relieve daily tension and stress through mindful movement, energize and motivate with home workouts like yoga and guided running, 28-day mindful fitness and cardio classes, training with experts and Olympians.

Other characteristics of Headspace include enabling group meditation participation and use of audio bars to adjust relative volume of ambience and voice during meditation. The application also provides instructors’ profile and introduction under ‘About your teacher’.

According to O’Daffer et al. [17], there are 14 randomized controlled trials (RCT) to date for Headspace, with the majority of participants being non-clinical populations (Table 3). The Headspace studies have an average of 103 participants (except for one RCT with 994 participants [18] and primarily measured mindfulness, well-being, stress, depressive symptoms, and anxiety symptoms. 75% of the studies reported improvements in depression and the results for other variables such as anxiety symptoms were mixed, but at least 40% of studies showed improvements for each of these outcomes. Four out of the fourteen studies (29%) did not report adherence data, and three studies (21%) required participants to provide self-reported usage data. However, most clinical studies were not powered to detect small or medium effect sizes, and app adherence was not uniformly measured.

MindDoc

MindDoc was developed with clinical psychologists and researchers for people who experience mild to moderate mental health problems (depression, anxiety, insomnia, and eating disorders) and want to learn about emotional well-being. Therefore, it provides courses and practices on a variety of topics such as depression, chronic pain, sleep, mental illness, confidence, living a full life, getting active, relationships, coping with COVID, etc. The ‘Courses of the Month’ provide structured and detailed information on anxiety-related topics. MindDoc asks, three times a day, 10 questions each, about how distressing one feels, one’s current feelings and thoughts and so on. Next it synthesizes responses to reveal topics that are most relevant at the moment (e.g., physical health, mood, strong inner criticism, etc.). If it is answered every day, one will receive an ‘Emotional Health Assessment’ after two weeks.

The application is registered as ‘Class 1 medical product’ according to the European Medical Device Regulation. It provides graphs for patterns such as symptoms, behaviors and overall emotional health. MindDoc puts emphasis on the connection between body and mind and takes dimensional perspective on understanding mental illness rather than segmental or category-based. The company has conducted a RCT with 1,000 subjects at the University of Berlin and they share anonymized data with institutions such as the University of Kassel, Columbia Business School, and the Max Planck Institute for Psychiatry for future research.

For MindDoc, an RCT recruiting over 1,000 participants at Freie Universität Berlin found improvements in attitudes toward mental health, self-care behaviors, healthcare utilization, and quality of life when using the app, with effect sizes between d=0.17 (odds ratio [OR]=1.36) and d=0.37 (OR=1.96) (Table 3) [19].

Rootd

One of Rootd’s core features, ‘The Rootr’ is a panic button to bring a swift help to fight off panic attacks based on the latest techniques in CBT. Based on one’s responses to their current feelings, it presents sentences that provide relevant facts for negative feelings and sentences that reinforce confidence for positive feelings. Long-term and short-term lessons provide reading material to learn where anxiety comes from, how the body and mind experience panic attacks, and why they happen. ‘Journal’ helps one identify unconscious triggers of anxiety and panic attacks by checking one’s mood and habits. One can choose their current feeling as an image and be given space to write about three things they accomplished today, something that weighs them down, something to be grateful for, and so on.

Rootd provides ‘Lesson Takeaways’ at the end of each lesson that effectively summarize the material, after which one can be directly led to Journal or Stats to reflect on their learning. ‘Emergency contact’ allows one to call a friend or family member or a nearby help center right from the app. One of the application’s conveniences is that there is voice support for most text contents. There were no ongoing or registered RCTs for Rootd.

MindShift CBT

MindShift CBT is evidence-based strategies and tools based on CBT for appropriate remediation and management of anxiety disorders. Users can learn about different CBT strategies, such as keeping a thought journal, challenging belief experiments, building a fear ladder, and challenging one’s comfort zone. Users can track their progress with check-ins that allow them to log and view graphs and journals. Users are guided to set goals and receive reminders. If desired, user data can be exported and shared via email to streamline their sessions with the therapist, counselor, or psychologist they work with.

The application offers ‘Community Forum’ which is a safe environment for people to share their stories and offer advice to each other. It has many effective tools such as Coping Cards (statements) where one can create their own cards to help overcome anxiety, and Belief Experiments to challenge anxiety-provoking beliefs. ‘Chill Zone’ has various themes such as calm and mindful breathing, tense and release, mental vacation, public speaking, and body scan, and ‘Taking Action’ provides tips for facing fears, incorporating healthy habits and comfort zone challenges.

In a feasibility RCT with a total of eleven acute psychiatric inpatients, MindShift CBT did not show significant differences from baseline on clinical measures (generalized anxiety disorder [GAD]-7, Patient Health Questionnaire-9, etc.), but a semi-structured exit interview revealed that participants were generally satisfied with the intervention, and the application’s “chill zone” received consistently good feedback [20]. And Rappaport et al. [21] conducted an open-label 16-week trial in 380 adults and found improvements in anxiety and depressive symptoms, functional impairment, and quality of life. Effect sizes indicated moderate change in anxiety symptoms (d=0.61, p<0.0001), depressive symptoms (d=0.50, p<0.0001), functional impairment (d=0.55, p<0.0001), and quality-of-life (d=0.31, p<0.0001) (Table 3).

Youper

Youper is a well-organized A.I. chatbot-guided CBT application which helps users to access their mental and emotional state and gives advice on mental health issues through chats and interactive exercises. Once a goal or agenda is set through chatting, various solution options are offered such as changing thoughts, practicing mindfulness/gratitude/acceptance/self-compassion, changing behavior, planning something fun, planning to connect with someone, etc. When a conversation is complete, it is saved to the ‘Me’ tab, where users can view, delete, or change the date of the saved conversation.

Activities such as meditation, listening to sleep music and nature sounds can be selected from tags such as ‘SOS,’ ‘Mindfulness,’ ‘Positive,’ ‘Depression,’ ‘Personal growth,’ ‘Work,’ ‘Relationships,’ ‘Loss,’ etc. in the ‘Explore’ tab. The ‘Symptoms’ tab lets the user answer some questions and see if they have mental health symptoms. It provides screening for conditions, symptoms monitoring and tracking health data. Anxiety, depression, borderline personality, panic, PTSD, and social anxiety can be screened, and one can pause function for monitoring while the check-up is available at monthly intervals.

Mehta et al. [22] examined the acceptability and effectiveness of Youper (Table 3). Users of Youper rated the app very highly, with approximately 43% of all 4,517 participants retained by week 4. Effectiveness analyses confirmed that improvements in anxiety were maintained for four consecutive weeks after using Youper, and that the frequency of emotion regulation in conversations predicted reductions in depressive and anxiety symptoms [22].

Common attributes of the applications and comparison with existing treatment mechanisms

The attributes that panic disorder treatment applications reviewed have in common is 1) a journal and check-in function that records current moods, thoughts, emotions, and situations, and that such records are aggregated into monthly stats, 2) short guides that can be used quickly when symptoms occur, 3) materials to understand and learn about panic/anxiety disorder, and audiovisual materials such as guided meditation and sleep to relieve symptoms (Table 4). The journal and check-in functions of these applications enable continuous self-monitoring and insight into one’s physical, emotional, and mental needs and conditions. Guides and course programs provide psychosocial education and training to help users feel at peace in their daily life as well as coping skills for when symptoms arise. In addition, whenever activities (such as journaling) are performed, feedback such as cheering messages, inspirational phrases, and/or points are given, and as the activities performed consistently remain in the statistical records, users may feel a sense of reward.

Table 4.

Comparison of functions across applications for treating anxiety symtpoms

Taken together, these applications are embodying and implementing well the elements of CBT, an established treatment for anxiety/panic disorder. Such elements involve psychological education and cognitive correction, emotional recognition and expression, skill training (emotion control, mindfulness, acceptance and commitment, etc.), contingency management (giving rewards), skill training and so forth. On the other hand, programs typically afforded by traditional exposure therapy such as gradual desensitization, thought experiments, exposure to reality or to imagination, are relatively hard to implement into an application. It is also difficult to follow through users’ challenges such as creating good habits, improving one’s environment, and/or escaping one’s comfort zone. The applications also inevitably lack deep empathy and acceptance that can be gained from human-to-human communication.

DISCUSSION

To summarize the main functions of anxiety symptom treatment applications, meditation, breathing training, journal for observation and educational materials were mainly provided. Compared to existing treatments, the applications have advantages such as high convenience/accessibility, no restrictions in time and space, reduced cost, mixed use of audiovisual materials and texts, quality programs provided by professional therapists and educators, and the provision of reminder and feedback functions.

The results of RCTs on the efficacy of the applications generally demonstrate small to moderate effect sizes in reducing symptoms of anxiety. However, most studies targeted nonclinical populations. Only two studies focused on psychiatric patients, they did not specifically target patient with anxiety disorder, and their results did not show significant improvement in anxiety symptoms. Except for headspace, which has 14 RCTs, most applications have only one or two RCTs, meaning that more clinical trials are needed to support the clinical effectiveness of these applications. There are also limitations to these applications, such as adherence rates reaching only around 50%, and a predominance of non-clinical populations among the target users. Further, the lack of targeting specific anxiety disorders (e.g., panic disorder, GAD, and social anxiety disorder) leads to the current applications having somewhat ambiguous mechanisms of action.

It is also important to consider the effectiveness of treatment and the usability of the application, such as user experience and interface, in the development of an application. The application has a limitation in that it is difficult to implement experiments or interaction and cooperation with the therapist, which are critical variables in traditional face-to-face treatment. In contrast, the applications attract people as it can provide more specific and fun rewards for activities, however small, in a form that can be used in the application itself such as premium vouchers, points, or cash. They can also adopt more interactive and engaging designs using animations or pop-up messages. Taking advantage of this, it would be important to organize the contents of the application as interactively as possible and to provide a space for journaling, reminders, and feedback on the performance of treatment training to increase user motivation.

Considering the above, the development of Korean anxiety disorder treatment applications in the future requires development centered on two axes: effectiveness and usability. First, in terms of effectiveness, efforts should be made to effectively implement exposure therapy, which is not sufficiently implemented in existing anxiety symptoms treatment applications. Anxiety-inducing exposure to reality is often painful for patients with anxiety disorders and usually accompanied by a desire to avoid it. However, exposure using simulation technology in the virtual world, such as metaverse, VR, and augmented reality, has advantages as it allows patients to predict or restore control over threatening situations. In addition, the level of spontaneity and motivation in treatment would be encouraged as the exposure intensity and time can be controlled by the participants themselves or through consultation with experts. On the other hand, to strengthen and maintain the motivation to participate in using the application, it is important to have mutual feedback and support between the patient and the expert. To this end, it is necessary to not only check the level of symptoms and treatment directions in regular face-to-face counseling, but also introduce an in-application counseling system to help participants experience recognition and rewards for their efforts and solve problems.

Improvement in terms of usability requires consideration of the integrated use of active and passive management functions using lifelog data and the development of elements that give pleasure and fun to the user. Whereas the existing applications put more focus on active monitoring (such as users’ monitoring, recording, and learning about their own conditions), the importance of passive monitoring will become more significant using lifelog data (as in sleep/exercise records, heart rate variability, etc.) recorded without the user’s constant effort or even consciousness. In addition, it is necessary to improve the user interface by introducing aspects of gamification such as target stages, rewards, and leaderboards, and smoothing the operation within the app. In the near future, Large Language Model or ChatGPT4 and similar technologies are expected to revolutionize mental healthcare applications. Current chatbot-based programs incorporating CBT skills struggle with natural, free-flowing conversations. Advances in technology and interdisciplinary cooperation are needed to address ethical considerations such as privacy, accuracy, reliability, and the nuance and complexity of mental states.

CONCLUSION

Based on accessibility and scalability, digital health care applications enable fundamental treatment interventions that continuously intervene in the lifestyle, behavior, and mindset of patients. Considering Korea’s unique circumstances, such as the high suicide rate, high levels of depression and anxiety among the younger generation, psychological barriers to mental health treatment, and very low utilization of mental health services, the value of its use will become more important in the future. Identifying mechanisms of action and demonstrating efficacy through sophisticated experimental designs for the treatment of specific anxiety disorder is essential to the development of digital mental health care applications. It is necessary also to think of ways to achieve publicity after developing the application so that many people can enjoy the benefits of digital therapy and conveniently use it.

Article information Continued