In my pocket, I have a miniature penguin to whom I’ve started confiding my fears. I told it I felt worried about a second wave of Covid-19, and it suggested I run through worst-case scenarios – and then assess how likely they were to happen. Once I’d concluded that they were in fact unlikely, I found that I felt reassured.
Which is odd, given that I was, after all, talking to a penguin. Not a real penguin, of course, but an artificial intelligence app on my phone called Wysa, which I have stored alongside Headspace, a tool for mindfulness, and eQuoo, an adventure game to improve my emotional intelligence.
This is the world of digital therapy, and these are among 600 approved mental health apps available on prescription. In the past six months, prescriptions for such apps have increased by 6,500 per cent. Now, hundreds of people a day are downloading a prescription app to help them address mental health issues.
Ross O’Brien, associate director of innovation and technology for Central and North West London NHS Foundation Trust, and the programme lead for Digital Improving Access to Psychological Therapies (IAPT) services, says this increase is directly as a result of the pandemic.
“People want support now. A digital app gives direct and rapid help and is instantly available,” he says. “Apps have a range of uses, both as a tool while someone is on a waiting list to see someone, or if someone’s condition isn’t serious enough for them to be referred for talking therapy.”
If a doctor refers a patient for talking therapy, such as cognitive behavioural therapy (CBT), the average wait is 12 weeks for a first face-to-face assessment, with a further wait of up to 12 weeks for treatment. Within children’s mental health, the National Institute for Health and Care Excellence guidelines now advocate for digital-first treatments.
Emma Selby, a mental health clinical nurse consultant, is co-founder of Wysa and an adviser on the new BBC language and communication platform Tiny Happy People. She has spent her career making sure that help finds the people who need it, rather than expecting them to do the work. With teenagers, she found this meant providing digital services.
She united with developers Jo Aggarwal and Ramakant Vempati to create Wysa. It was initially aimed at young people – but of the two million people worldwide now talking to the AI penguin (chosen because “no one is scared of penguins”, Selby explains), the majority are adults. It will help with anything from marital problems to exam fears.
Selby has developed modules specifically for medical staff who worked through the first wave of Covid-19, many of whom found it hard to say they were worried or scared. The creators received a grant to make it free to all teenagers in the UK during the Covid crisis.
It’s also available on prescription, and for adults there’s a premium level where clinicians monitor wellbeing levels, which costs £4.99 a month. The NHS is carrying out research to see whether making the app free to everyone would help to reduce the number of people needing mental health service help.
Last year, 1.6 million referrals were made to adult mental health services. Selby is adamant that digital therapies do not replace face-to-face services.
“Mental health is more underfunded than any other part of healthcare,” she says. “Early intervention [to help people with mild mental health problems] has been decommissioned gradually over the past decade. So you now have someone self-harming on the same waiting list as someone with panic attacks, even though they might not need the same treatment approach.
“If you can give people tools to help themselves it means you can help those with severe problems more quickly.”
O’Brien agrees that apps are not a replacement for face-to-face therapy, but a complement. “We have a blended approach, and when using apps clinically it’s helpful to have a therapist as a guide to stop people becoming disengaged and dropping off from accessing the help. They are not a standalone treatment: the digital still needs a human.”
But, he says, they are effective for all ages. “There’s a false perception that mental health apps are for young people, and while they are more likely to be picked up by younger adults, this is not at the exclusion of those who are middle-aged and older adults.”
One app that is aimed at young people is eQuoo, which makes emotional intelligence into an adventure game. Silja Litvin is the clinical psychologist behind it.
She started her career by working with young adults with eating and mood disorders. “When you study psychology, you don’t learn about the healthcare system and lack of funding. So I was really shocked to see people had been on waiting lists for months,” she recalls.
In 2016, she researched evidence-based computer interventions and created her first mental health app. “It significantly lowered anxiety levels; the effect was equivalent to taking a beta blocker,” she says.
But she found that drop-off rates were high. People on average spend two minutes on a mental health app and delete it after two weeks, according to the American Psychology Association.
“Seventy per cent of young adults are casual gamers, so we decided to wrap our therapy into a game,” Litvin explains. eQuoo went live in December last year and the next generation will launch at the end of this year. There have been more than 100,000 downloads, with a 160 per cent spike during lockdown.https://6e7214b5c249ad78710f4b4f96fe22f5.safeframe.googlesyndication.com/safeframe/1-0-37/html/container.html
And Litvin is delighted that users stay engaged: 95 per cent of people keep using the app, spending 15 to 20 minutes online during a session.
Another app aimed at young people is Calm Harm. The clinical psychologist behind it, Dr Nihara Krause, worked with young people to create the free app. “The analogy the app uses is that the urge to self-harm is like a wave. It feels the most powerful when you start wanting to do it. Learn to surf the wave.
“Once you surf the wave the urge will fade. This analogy helps the user to understand that they can have control over self-harm if they can carry out certain tasks to manage difficult impulses. The app provides five- or 15-minute tasks in four categories: comfort, distract, express or release.”
More than 1.5 million people have downloaded the app across 171 countries. “We notice sharp peaks in downloads which coincide with real-life events, the most recent being a doubling of downloads when the A-level results were initially announced,” Krause says.
ORCHA (Organisation for the Review of Health and Care Apps) is the leading evaluator of health apps, assessing apps’ clinical assurance, user experience and data privacy. These are some of its highest-rated apps:
Wysa scores top in all the main mental health categories. It draws on techniques such as cognitive behaviour therapy, mindfulness and breathing techniques, packaged into accessible exercises. It is clinically assessed and tested, and recommended by a number of NHS trusts.
Cost: From £5 per month for premium package. Therapist package from £200 for eight sessions over two months.
This app scores more highly than the better known Headspace app for relaxation, meditation and mindfulness, though both are highly rated (and Wysa is rated first once again). Uses clinically verified mindfulness techniques to provide personalised help.
Cost: Premium access free for duration of coronavirus outbreak. There are in-app purchases.
The hugely popular app is one of ORCHA’s most highly rated for sleep, though it also contains hundreds of guided meditations – and soundscapes – to address a range of mental wellbeing issues. Scores slightly less highly for data privacy.
Cost: £9.99 per month or £49.99 per year.
In total, more than 380,000 health apps are available through Apple and Android operating systems, and around 20,000 of them address mental health. But not all are made equal.
Liz Ashall-Payne is the founding chief executive officer of the Organisation for the Review of Health and Care Apps (Orcha), which evaluates health apps, working with governments and health bodies, including the NHS, in 11 countries. Its approval is the equivalent of the kite mark for condoms: avoid any health app without it.
“The biggest problem with digital health apps is knowing which are high quality and safe,” she says. “If you tap in anxiety or depression into the Apple store, you won’t know which apps are good. As a clinician prescribing to patients, you also want to know an app is safe and will do what it promises.
“Just under 30 per cent of mental health apps meet the quality threshold that we set.”
Approved apps do not store any user details and they also have to be clinically safe. “We should have more regulation for apps with health content,” Ashall-Payne believes. “This isn’t music or gaming.”
She says there are 2,500 regulations, standards and best practice guides that could apply to any health app, and many doctors, patients and carers who create apps don’t necessarily know which apply.
“We don’t want a divide between regulation and innovation,” she adds. “We help innovators get their product into market faster and help them improve, because while there are lots of apps, we still don’t have enough good ones.”
Part of Orcha’s role is to classify apps so that a GP can find the best prescription for, say, a teenager with anxiety. But Ashall-Payne says that digital health solutions have a role in prevention as well as treatment.
One of the best known preventative mental health apps is Headspace, founded in 2010. It has a reach of 65 million people in 190 countries and has reported a 20 per cent rise in downloads since mid-March.
Jolawn Victor, its chief international officer, said: “The ‘stressed’ meditation has seen a five-and-a-half times increase in the UK over the past six months. The ‘reframing anxiety at-home workout’ has seen a fourfold increase in the UK during that time too.”
Headspace launched a free “Weathering the Storm” collection of meditation and mindfulness content to help users this year, and has offered NHS workers free subscriptions for 2020.https://6e7214b5c249ad78710f4b4f96fe22f5.safeframe.googlesyndication.com/safeframe/1-0-37/html/container.html
For those concerned that reliance on phones could have a negative impact on mental health, Victor says: “Offering mindfulness content digitally means people can meditate wherever and whenever they need it. It’s just about finding a healthy balance of being mindful with our technology.”
I turn to my pocket penguin and say that I’m worried about how much time I’m on my phone now I’ve downloaded these apps. It prompts me to find solutions: mainly spending less time online and suggests we work through a resilience-building exercise.
I initially downloaded the penguin for research, but I’m going to keep it on my phone, just in case.