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AHRQ: Agency for Healthcare Research and Quality

Potential Usefulness of Apps and Other Digital Technologies for Improving Access to Behavioral Health in Primary Care

Purpose

The role of digital technologies in behavioral healthcare, including telehealth and smart phone or computer-based apps, is growing. Persistent workforce shortages in behavioral healthcare — particularly in rural areas — have helped drive the trend toward using technologies to expand the availability and the quality of care. "One in five individuals over the age of 18 experienced a mental health condition in 2021,[1] and one in six individuals over the age of 12 experienced a substance use disorder.[2] Fewer than half of these individuals received the behavioral healthcare they needed.[3] The ability of apps and other digital technologies to connect people and information across time and location makes them a potentially valuable support to efforts to integrate behavioral health and primary care." These developments have been spurred by restrictions during the COVID-19 pandemic, and by the accumulation of evidence for the acceptability and effectiveness of selected technology-assisted approaches to treatment and recovery support.

At the same time, apps and other digital technologies can be challenging to implement and do pose some level of risk to patients with behavioral health conditions. There is no single governmental or private organization that assesses these digital tools and certifies them as to privacy, safety, or effectiveness.[4] Thousands of behavioral health apps are currently available in commercial app stores, but it's been estimated that only 3 to 4 percent are evidence based.[5],[6] While some of these apps have been extensively studied and shown to be efficacious, the vast majority (an estimated 98 percent) have not been systematically evaluated.[7]

This brief provides an overview of the state of the evidence for behavioral health apps and key considerations and concerns related to finding, evaluating, and selecting smartphone and Internet-based behavioral health apps to recommend or prescribe in primary care and integrated care settings. Additionally, this brief outlines how healthcare professionals, policymakers, and researchers can improve and expand the safe and effective use of behavioral health apps in primary care and integrated care settings. While the field of digital healthcare is too young for definitive guidance, this brief aims to provide some basic information on what behavioral apps are, the benefits and risks of recommending apps for your patients, questions to think about when selecting an app, and further sources of information.

Marsch LA. Digital health data-driven approaches to understand human behavior. Neuropsychopharmacology. 2021 Jan;46(1):191-196. https://doi.org/10.1038%2Fs41386-020-0761-5. Accessed May 11, 2023. [adapted]

Behavioral health apps are programs or software applications designed to run on computers and mobile devices, such as phones, tablets, or watches, to support management, treatment, diagnosis, and recovery for people with mental health and substance use disorders, life stressors and crises, and stress-related physical symptoms.

Behavioral health apps are an example of digital medicine. They can:

  • Capture, store, and transmit health data;
  • Support diagnosis, patient monitoring, and self-management;
  • Connect users to behavioral health professionals and peer support;
  • Deliver behavioral health interventions; and
  • Be used with the support of a healthcare professional (guided) or used without human support (unguided and fully automated).

Behavioral health apps that deliver evidence based behavioral health interventions and therapies are called digital therapeutics. A very small subset of digital therapeutics has been evaluated and approved by the FDA for use with a prescription and are called prescription digital therapeutics.[8] Digital therapeutics manufacturers are required to register and list their products with the FDA. However, most digital therapeutic apps are classified as presenting a low to moderate risk to patients, and FDA clearance is not required before marketing those apps in the United States.[9],[10]

Behavioral health apps are designed to target several behavioral health conditions, including:[11]

  • Anxiety disorders;
  • Attention-deficit/Hyperactivity disorder
  • Bipolar disorders;
  • Depressive disorders;
  • Feeding and eating disorders;
  • Obsessive-compulsive and related disorders;
  • Personality disorders;
  • Schizophrenia spectrum and psychotic disorders;
  • Self-harm;
  • Sleep-wake disorders;
  • Substance-related and addictive disorders; and
  • Trauma- and stressor-related disorders.

While most commercially available behavioral health apps are not digital therapeutics or prescription digital therapeutics, they do provide features that can be beneficial, such as psychoeducation, symptom and other health data tracking, goal and habit setting, mindfulness meditation and other coping techniques to patients with behavioral health conditions.[12]

There is no agency responsible for monitoring and evaluating the approximately 20,000 behavioral health apps on the market. However, only an estimated 2 percent of behavioral health apps included in the commercial markets are supported by original peer-reviewed research publications on efficacy or feasibility.[13] Efficacy is used here to refer to findings that the app has been shown to achieve desired outcomes in controlled clinical research settings. Effectiveness is used here to indicate that desired outcomes have been achieved in real-world clinical settings.

The nature of behavioral health apps presents several challenges in research design for controlled and real-world clinical settings, such as establishing appropriate control groups or maintaining blind conditions in randomized control trials (RCTs), that contribute to the limited clinical evidence of efficacy and effectiveness.[14] The existing RCTs, meta-analyses, systematic reviews, and pilot and feasibility studies focus mainly on the small number of behavioral health apps that are considered digital therapeutics and prescription digital therapeutics.[15],[16] Both prescription and nonprescription digital therapeutics have demonstrated modest efficacy for addressing common mental health and substance use disorders, but these findings are impacted by limitations in methodology, design, and sampling.[17]-[57]While behavioral health apps show promising potential, the evidence of their effectiveness and safety is emerging and not definitive.

Below is a sample of available studies on behavioral health apps.

One in five individuals over the age of 18 experienced a mental health condition in 2021,[58] and one in six individuals over the age of 12 experienced a substance use disorder.[59] Fewer than half of these individuals received the behavioral health care they needed.[60] Apps have the potential to improve availability and accessibility of behavioral healthcare services and increase the capacity of integrated behavioral health efforts in primary care.

Behavioral health apps can mitigate common barriers to accessing behavioral health care.

  • Behavioral health apps can expand the capacity of the existing behavioral health workforce. Many behavioral health apps are designed to complement and extend the services provided by the care team, with features such as automated behavioral therapy and learning modules. For example, the U.S. Department of Veterans Affairs (VA) National Center for PTSD offers several apps that, "provide self-help, education and support following trauma."[61] There are also several behavioral health apps that maintain a salaried team of peer support specialists who can monitor and reach out to patients routinely or in times of difficulty, and alert clinicians if needed.[62],[63] These apps allow access to peer and recovery supports that supplement clinical care without the need to hire additional staff in the clinic. This expanded capacity can be especially beneficial in rural areas or at any primary care setting affected by workforce shortages. Some clinicians report providing apps to patients who are on waiting lists or having difficulty accessing healthcare services in their community.[64],[65],[66],[67]
    • Behavioral health apps can serve as an effective adjunct to other ongoing behavioral health treatment. Many apps are intended for use as adjuncts to more traditional in-person or telehealth treatment interventions, and have been found to be effective when used this way.[68] For example, the VA National Center for PTSD offers several "coaching apps" that are intended to serve as "treatment companion apps, for use with a health care provider, to make treatment easier."[69]
    • Some behavioral health apps can be effective when used on a standalone basis. There is some evidence that some behavioral health apps can also be effective when used in place of conventional face-to-face or telehealth treatment.[70],[71] Electronically delivered cognitive behavioral therapy (CBT), for example, was found to be more effective than face-to-face CBT in a 2020 systematic review and meta-analysis.[72]
  • Behavioral health apps can remove implementation barriers for evidence based treatments.
    • Apps can make it possible to virtually deliver several well-established, evidence based behavioral health psychotherapies, such as cognitive behavioral therapy (CBT), motivational interviewing (MI), contingency management (CM), community reinforcement approach (CRA), and acceptance and commitment therapy (ACT). CM, for example, is one of the few effective treatments for stimulant use disorder and other substance use, but can be complex to set up and operate.[73],[74] Apps can provide a ready-made structure for CM implementation, allowing CM to be more easily offered in primary care.[75],[76],[77],[78],[79] Virtual delivery of these interventions can help to address barriers to treatment, like transportation and staffing shortages.[80],[81] However, it is also important to consider limitations related to access to the technology, cost, and cultural and linguistic appropriateness when considering a role for apps.
  • Behavioral health apps can remove engagement barriers and increase the convenience of engaging in behavioral health treatments.
    • Many behavioral health apps allow patients to communicate with behavioral health providers and peer support via text, audio, and video. During the COVID-19 pandemic, individual and group therapy sessions and peer support groups were conducted using apps and phone-connected devices.[82],[83],[84]
    • Some behavioral health apps allow patients to participate in remote drug testing. Some apps and phone-connected devices are able to use self-administered, remote, video-monitored breath and saliva testing for substance use or to confirm medication adherence, reducing the need to travel for treatment and drug testing.[85],[86],[87]
    • Behavioral health apps have high acceptability among patients. Contrary to some initial concerns, most patients find apps acceptable for behavioral health treatment, including patients with little or no prior smartphone experience and older and digitally naïve patient groups.[88],[89],[90],[91],[92],[93]

Multiple organizations have proposed review criteria for behavioral health apps, but no single organization provides definitive information about the thousands of apps available.[94] Until a regulatory body and standardized review system and framework is established and widely adopted, patients and providers will have to make their own assessments.[95],[96] There are several governmental and independent organizations that provide ratings and reviews of some behavioral health apps. Links to some of these app databases and listings are provided in the next section.

Following a review of several notable frameworks for assessing health apps, the Agency for Healthcare Research and Quality has developed the Framework to Assist Stakeholders in Technology Evaluation for Recovery (FASTER) to Mental Health and Wellness. This systematic review has identified several common criteria for assessing behavioral health apps, including clinical evidence of efficacy, data privacy and security, usability and accessibility, functions for remote patient monitoring, interoperability and data sharing, and app use and alignment. The FASTER Framework also provides questionnaires that primary care providers and care team members can use to assess behavioral health apps using these criteria. It should be noted that there is as yet no single organization that is applying the FASTER criteria to the large number of behavioral health apps.

Clinical Evidence of Efficacy

Most of the approximately 20,000 behavioral health apps available in commercial app stores are not evidence based and have not been rigorously tested for efficacy. Efficacy is used here to refer to findings that an app has been shown to achieve desired outcomes in controlled clinical research settings, as implementation in real-world clinical settings presents many challenges. It is important to verify app claims, because false claims are common.[97] Behavioral health apps may claim to be evidence based; but only an estimated 3 to 4 percent actually are.[98] Moreover, apps that claim to use an evidence based theoretical framework may lack published evidence of their efficacy.[99] A 2020 systematic review concluded that, "Only 2.08% (21/1009) of publicly available psychosocial wellness and stress management mobile apps discoverable to self-help seekers have published, peer-reviewed evidence of feasibility and/or efficacy."[100]

  • Is the app based on evidence based behavioral health frameworks, interventions, and approaches? An evidence based app will have fidelity to core elements of the evidence based framework, intervention, or approach it is using. While being evidence based is generally better than not, it is also important to review the published evidence of an app's efficacy.
  • Has the app been shown to be efficacious? Randomized clinical trials (RCTs) and meta-analyses or systematic reviews can provide that information.
    • Check to see that the app(s) included in a study (PDF - 1.03MB) were used in a relevant setting with participants who represent the target population of interest.
    • Take note of research methodology and whether studies were conducted by independent researchers (preferred) or paid for by app developers or other entities with a vested interest in the success of the app.

Data Privacy and Security

Behavioral health apps deal with very sensitive personal information and health data. It is important to understand an app's policies, security, ownership, and funding sources. A systematic assessment of popular behavioral health apps found 44 percent of the studied apps shared personal health information with third parties.[101] Apps may be collecting user data without obtaining consent, or requesting permission to access elements of users' mobile devices without having a privacy policy.[102],[103] Apps may have a privacy policy in place, but may not be in compliance with that policy.[104],[105] Apps may also be sharing data with third parties that are then sharing data with additional entities.[106]

  • Does the app have a transparent privacy policy that is clear and accessible before use?
  • Does the privacy policy disclose the collection, storage, use, and/or transmission of sensitive data? If yes, check to see if the app claims to do so securely and in compliance with industry standards.
  • Are there any potential conflicts of interest that could jeopardize data privacy and security? For example, if an app is free of cost, could it be using a business model that relies on selling patient information and health data?

The resource below provides reviews and ratings for a small number of apps specifically on their policies and practices related to protecting the confidentiality of personal data.

Usability and Accessibility

Ideally, developers involve real patients in the app development process to ensure that the app's features are easy to understand and use. Poor usability and lack of relevant and customizable content are common reasons why users abandon behavioral health apps.[107],[108],[109] Systematic assessments of popular behavioral health apps have found that nearly half or more of the apps assessed did not meet criteria for ease of use, engagement, and customizability; did not have accessibility features; and were only available in English.[110],[111] Only 39 percent of behavioral health apps were completely free.[112] It is important to consider the usability and accessibility of an app before deciding to recommend or prescribe it.

  • Were patients involved in designing and testing the app to make sure it is easy to understand and use? Involving patients and other potential users, including clinicians, in this way is referred to as user-centered design. An app with a user-centered design will be easy for patients and providers to use, and responsive to the goals and needs of users.
  • Does the app have accessibility features? Accessibility features provide the ability to enlarge text size, enable text-to-speech or speech-to-text, access closed captioning, and adjust color schemes.
  • Does the app require access to the internet? Inadequate or unaffordable broadband and data plans and insufficient financial support for those who are un- or underinsured result in disparities in the uptake of digital health technologies.[113],[114],[115]
  • Does the app have offline capabilities? If so, the app will store data when there is no internet connection or phone carrier access, and then transmit the data when a connection is available. This can be an especially important consideration in rural areas with limited broadband.
  • Is the app culturally and linguistically appropriate? Culturally and linguistically appropriate apps allow users to access content that is in the language they are most comfortable with and that reflects their culture.
  • Will the app cost patients and if so, how much? Many behavioral health apps are direct-to-consumer and may require the end user (the patient) to pay out-of-pocket for in-app purchases or paid subscriptions in order to access full functionality.[116],[117]
  • Is there external financial support for app adoption and use? Some state Medicaid programs, managed care organizations (MCOs), and private insurance companies are providing funding to test or support the implementation of particular behavioral health apps.[118],[119]

Functions for Remote Patient Monitoring

Many behavioral health apps use patient-reported outcome measures (PROM) questionnaires and other methods to collect patient data and monitor patient status and outcomes outside of the clinical setting.[120],[121] A systematic assessment of popular behavioral health apps found that mood-tracking, journaling, and symptom-tracking are among the most common patient data inputs, and that 15 percent of the apps assessed were collecting passive data (e.g., biodata or geolocation) from sensors.[122] Data from PROM questionnaires, wearables, and other surveys and sensors can be used to support in-time clinical decision-making; provide real-time feedback and recommendations; personalize behavioral health support; and increase patient engagement.[123],[124],[125],[126]

  • Does the app enable PROM questionnaires? PROM questionnaires, such as the instruments listed in the NIH PROMIS system, PHQ-9 for depression, GAD-7 for anxiety, and Brief Addictions Monitor (BAM) for substance use disorders, can be used in clinical settings to screen for indicators that a patient may have a particular behavioral health condition.
  • Does the app support self-monitoring? Encouraging patients to use PROM measures on a periodic or regular basis via apps can support self-monitoring and assess progress toward recovery.
  • Does the app offer geo-tracking? With appropriate privacy protections and patient permissions, it is possible to use the geo-tracking capability of smartphones to determine if a patient was present for a treatment session or a recovery support group. Some apps have also used geo-tracking to alert the patient if they are approaching self-identified dangerous areas, such as neighborhoods with street drug trafficking, liquor stores, or bars.
  • Does the app send notifications to patients and caregivers? Push notifications and text messages can prompt patients to take medications, and appointment reminders can help to reduce no-shows.
  • Does the app include behavioral health crisis features? Some apps include a help button that can be used at a time of crisis to reach out to a clinician or trusted peer.[127],[128]

Interoperability and Data Sharing

Some behavioral health apps offer users the option to export or share their data with a third party (e.g., a clinician). A systematic assessment of popular behavioral health apps found that 30 percent of the apps assessed allowed users to email or export their data, and 2 percent offered integration with an electronic health record (EHR).[129] Providing users the ability to share data in an accurate and clinically meaningful way may contribute to clinician and patient engagement with the app and the accomplishment of the therapeutic goals.

  • Does the app facilitate data sharing between patients and clinicians? If the PROM or other patient monitoring results are shared with clinicians, the information garnered from the PROMs can also help to improve the responsiveness of treatment. Data sharing provides providers with the clinical information needed to tailor behavioral health treatment session content to issues of immediate relevance to the patient.
  • Does the app aggregate data? Can the PROM data be aggregated across patients at the level of the clinic or the individual clinician to provide indicators of clinical and program effectiveness? Data aggregation is essential for providing measurement-based care, a proven approach to quality improvement (QI).[130] Using apps to collect PROMs data and health indicator data from wearables makes it possible to access PROMs at any time or place and aggregate the data for QI.
  • Does the app have the capacity to integrate with an EHR (PDF - 6.1 MB) or does it have a clinician dashboard that allows behavioral health providers to monitor patient-shared data? Features that minimize the disruption of clinician routine increase the likelihood that clinicians will take advantage of apps.

App Use and Alignment

Behavioral health apps are typically introduced as part of a comprehensive treatment plan that complements other services and supports, rather than used as a standalone intervention. [131]

The following questions are important to consider when planning to recommend or prescribe behavioral health apps to a patient.

  • Is the patient able to use an app and interested in using an app?
  • Is there an evidence based app that can provide treatment for the patient's condition?
    • Identifying the "active ingredient" in the app (the evidence based framework, approach, or intervention it is based on) can provide some perspective on how useful the app may be.
  • Does the app support the patient's therapeutic goals?
    • For example, apps that are abstinence oriented for alcohol use disorders are not going to be a good fit for the patient interested in a harm reduction approach.
  • Is the patient willing to follow the treatment protocol provided in the app?
    • Assessing the patient's interest and confidence in following the treatment plan of the app will be useful in determining the utility of the app as well as help solve any treatment adherence problems.
  • How will the app fit into the patient's overall comprehensive treatment plan?
    • Is the app a central feature to support behavioral change in between visits, or is it primarily educational? Determining the app's place will help providers prioritize how closely they should follow a patient's use of the app.
  • Is the patient already using an app for their behavioral health goals?
    • Screening patients about behavioral health app use and documenting that use provides more comprehensive clinical information and allows for informed decisions during treatment planning. Non-prescription apps are comparable to dietary supplements. While patients self-direct their use, engaging with apps as they feel is appropriate for their needs, it is important to be proactive and aware of what they are using. Going through some of the questions above will be helpful in discussing the utility of these apps with patients.

The resource below provides key considerations for appropriate app utilization.

There are over 20,000 publicly available apps that target behavioral health, with an estimated 900 targeting alcohol and illicit substance use, specifically.[132],[133] Most of these apps are direct-to-consumer and publicly available to download and use from commercial app marketplaces (e.g., the Apple App Store or Google Play Store). Some apps, however, are limited to specific groups (e.g., health insurance members or health system patients) or may require a prescription (i.e., prescription digital therapeutics).

Inclusion in commercial marketplaces does not guarantee that an app has been evaluated for effectiveness or privacy protections, and consumer ratings do not correlate with professional ratings or with evidence of effectiveness.[134],[135],[136] To assist clinicians and consumers with finding and selecting behavioral health apps, several government agencies, professional associations, healthcare systems, and industry trade groups maintain behavioral health specific app listings and databases. Each listing and database use a different methodology and set of evaluation criteria to review and assess behavioral health apps.

The table below includes a sample of the available behavioral health app databases and listings. Be sure to understand the ownership, funding sources, and evaluation methods and criteria of any behavioral health app listing or database before using it to select apps to recommend or prescribe to patients.

Behavioral Health App Databases and Listings

Database/Listing

Organization Name

Organization Type

Evaluation Criteria

mHealth Index & Navigation Database (MIND)

Division of Digital Psychiatry at the Beth Israel Deaconess Medical Center

Collaborative research group in an academic medical center

Based on American Psychiatric Association's App Evaluation Model

One Mind PsyberGuide

One Mind

Non-profit organization

Based on app credibility, user experience, and transparency of privacy practices

Technology Assisted Care for Substance Use Disorders

National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) Blending Initiative

Federal agency

Based on research findings from the National Drug Abuse Treatment Clinical Trials Network (CTN) trials and other NIDA-funded treatment studies

Department of Veteran Affairs (VA) Mobile Apps for PTSD

VA National Center for PTSD

Federal agency

N/A - Features apps developed by the VA National Center for PTSD

Digital Therapeutics (DTx) Product Library

Digital Therapeutics Alliance (DTA)

Non-profit trade association of companies that manufacture, evaluate, and distribute digital therapeutics

Based on product availability and alignment with the industry's definition and core principles

New Zealand (NZ) Health App Library

Health Navigator Charitable Trust

Non-profit organization

Based on features, functionality, information quality, relevance to NZ audiences, clinical value, and usability

Self-Care App Listing

Kaiser Permanente (KP)

Healthcare provider and non-profit health plan

Based on usability, effectiveness, safety, and confidentiality

Implementing any kind of change in a clinical practice always presents challenges. While there are currently no comprehensive guidance documents on how to use behavioral health apps in primary care settings, common implementation steps emerge from the peer-reviewed literature:[137],[138],[139]

  • Assessing practice, staff, and patient readiness.
  • Identifying champions to build awareness and garner patient and provider support.
  • Allocating and securing sufficient funds for integrating behavioral health apps.
  • Determining how behavioral health apps fit into clinical workflows.
  • Determining if/how to hire or expand staff roles to support integration.
  • Establishing onboarding processes to provide education and training for staff and patients.
  • Establishing practice guidelines for integrating behavioral health apps.
  • Establishing plans for monitoring and addressing safety and privacy.

The following resources can also be adapted for using behavioral health apps in primary care and integrated care settings:

Implementation Guides

Readiness Assessments

Staff Trainings

Several larger healthcare systems have used behavioral health apps following some of these implementation steps.

  • Kaiser Permanente (KP) has taken a two-pronged strategy for implementing apps. They carefully vetted apps and provided training to clinicians on how to use and refer apps to patients (members). They then offered three apps directly to all KP members via the KP website. KP:
    • Drew on education and training materials from app companies to develop organization-specific materials;
    • Created a dedicated internal website for the clinician training program to house all materials; and
    • Created a patient-facing version of the website that houses three free basic mental health and wellness apps available to all KP members without referral.
  • The Digital Psychiatry Division of the Department of Psychiatry at The Beth Israel Deaconess Medical Center uses a model involving the development of special purpose software to share information and connect individual apps. The model builds from a single flexible app that allows symptom assessment, patient input into care planning, and support for measurement-based care. The model also includes the development of educational components for both members of the clinical team and for patients, and the creation of a new care team staff position, "digital navigator".
  • Northwestern University's Center for Behavioral Intervention Technologies has implemented a platform approach that bundles mental health apps into a suite. Each app included in the platform is brief and honed to a single clinical target. While the individual apps are available in commercial app marketplaces, when used in the platform, patients can receive recommendations about which apps may be the best fit for them.
  • Behavioral health apps are programs or software applications designed to run on computers and mobile devices to support management, treatment, diagnosis, and recovery for people with mental health and substance use disorders, life stressors and crises, and stress-related physical symptoms.
  • Integrating behavioral health apps into primary care can increase much-needed access to effective behavioral health services and improve the efficiency of those services.
  • Most behavioral health apps that are available for patient and clinician use have not been systematically evaluated in clinical trials.
  • Behavioral health apps that are considered digital therapeutics or prescription digital therapeutics have an emerging evidence base that suggests efficacy, but there are challenges with implementation and limitations in methodology, design, and sampling of research studies.
  • Before recommending or prescribing a behavioral health app, there are several considerations that need to be made regarding clinical evidence of efficacy, data security and privacy, usability and accessibility, functions for remote patient monitoring, interoperability and data sharing, and app use and alignment within existing treatment goals.
  • There is no single organization that assesses behavioral health apps. Using curated databases and listings when trying to find and evaluate behavioral health apps can narrow the options, versus searching commercial app marketplaces.
  • While there is no established process or comprehensive guidance for using behavioral health apps, several common steps have emerged from the literature and been used to implement behavioral health apps into large health systems.
  • Integrated care team members should familiarize themselves with the basics of behavioral health apps as outlined in this document, because patients are already using them and the potential to increase team capacity is present. Key knowledge base elements include:
    • Evidence base
    • What they can and can't do regarding treatment
    • Risks and benefits
    • Trusted websites and organizations that evaluate behavioral health apps
    • Accessibility
  • Determine the goals of using behavioral health apps, especially those that are digital therapeutics, for both patients and providers, and the targeted patient population.
  • Review how digital therapeutics and other behavioral health apps can be incorporated into your current team's efforts and how these apps will be supported.
  • Identify a clinical champion to advocate for and support this clinical effort.
  • Reach out to existing practices using these tools and learn from their experience.

For Policymakers

  • Develop standardized guidelines for data privacy and security for behavioral health apps.
  • Develop standardized evaluation and review criteria for behavioral health apps.
  • Establish an entity to oversee behavioral health apps.
  • Establish clear funding mechanisms to support research on the implementation of behavioral health apps in primary care.

For Researchers

  • Conduct more clinical research to determine if behavioral health apps in primary care provide improved health outcomes.
  • Conduct more financial analyses to determine if integrating behavioral health apps in primary care is financially sustainable.
  • Conduct more implementation research to determine ways to reduce the burden of incorporating behavioral health apps in primary care.

Research and Policy

[1] Results from the 2021 National Survey on Drug Use and Health: Graphics from the Key Findings Report. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2022. https://www.samhsa.gov/data/sites/default/files/reports/rpt39443/2021_NNR_figure_slides.pdf (PDF - 3.7 MB). Accessed May 15, 2023.

[2] Key Substance Use and Mental Health Indicators in the United States: Results from the 2021 National Survey on Drug Use and Health. HHS Publication No. PEP22-07-01-005, NSDUH Series H-57. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2022. https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report. Accessed May 15, 2023.

[3] Key Substance Use and Mental Health Indicators in the United States: Results from the 2021 National Survey on Drug Use and Health. HHS Publication No. PEP22-07-01-005, NSDUH Series H-57. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2022. https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report. Accessed May 15, 2023.

[4] Insel T. Digital mental health care: Five lessons from Act 1 and a preview of Acts 2-5. NPJ Digit Med. 2023 Jan 26;6(1):9. https://doi.org/10.1038/s41746-023-00760-8. Accessed May 15, 2023.

[5] Agarwal S, Jalan M, Wilcox HC, Sharma R, Hill R, Pantalone E, Thrul J, Rainey JC, Robinson KA. Evaluation of Mental Health Mobile Applications. Technical Brief 41. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 75Q80120D00003.) AHRQ Publication No. 22-EHC016. Rockville, MD: Agency for Healthcare Research and Quality; May 2022. https://doi.org/10.23970/AHRQEPCTB41. Accessed May 15, 2023.

[6] Lecomte T, Potvin S, Corbière M, Guay S, Samson C, Cloutier B, Francoeur A, Pennou A, Khazaal Y. Mobile apps for mental health issues: Meta-review of meta-analyses. JMIR Mhealth Uhealth. 2020 May 29;8(5):e17458. https://doi.org/10.2196/17458. Accessed May 15, 2023.

[7] Lau N, O'Daffer A, Colt S, Yi-Frazier JP, Palermo TM, McCauley E, Rosenberg AR. Android and iPhone mobile apps for psychosocial wellness and stress management: Systematic search in app stores and literature review. JMIR Mhealth Uhealth. 2020 May 22;8(5):e17798. https://doi.org/10.2196/17798. Accessed June 6, 2023.

[8] Watson A, Chapman R, Shafai G, Maricich YA. FDA regulations and prescription digital therapeutics: Evolving with the technologies they regulate. Front Digit Health. 2023 Apr 17;5:1086219. https://doi.org/10.3389/fdgth.2023.1086219.

[9] Brezing CA, Brixner DI. The rise of prescription digital therapeutics in behavioral health. Adv Ther. 2022 Dec;39(12):5301-5306. https://doi.org/10.1007/s12325-022-02320-0. Accessed June 6, 2023.

[10] Wang C, Lee C, Shin H. Digital therapeutics from bench to bedside. npj Digit Med. 2023;6(38). https://doi.org/10.1038/s41746-023-00777-z. Accessed June 6, 2023.

[11] Agarwal S, Jalan M, Wilcox HC, Sharma R, Hill R, Pantalone E, Thrul J, Rainey JC, Robinson KA. Evaluation of Mental Health Mobile Applications. Technical Brief 41. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 75Q80120D00003.) AHRQ Publication No. 22-EHC016. Rockville, MD: Agency for Healthcare Research and Quality; May 2022. https://doi.org/10.23970/AHRQEPCTB41. Accessed May 15, 2023.

[12] Camacho E, Cohen A, Torous J. Assessment of mental health services available through smartphone apps. JAMA Netw Open. 2022 Dec 1;5(12):e2248784. https://doi.org/10.1001/jamanetworkopen.2022.48784. Accessed May 15, 2023.

[13] Lau N, O'Daffer A, Colt S, Yi-Frazier JP, Palermo TM, McCauley E, Rosenberg AR. Android and iPhone mobile apps for psychosocial wellness and stress management: Systematic search in app stores and literature review. JMIR Mhealth Uhealth. 2020 May 22;8(5):e17798. https://doi.org/10.2196/17798. Accessed June 6, 2023.

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