Background Understanding patterns of real-world usage of mental health apps is key to maximizing their potential to increase public self-management of care. Although developer-led studies have published results on the use of mental health apps in real-world settings, no study yet has systematically examined usage patterns of a large sample of mental health apps relying on independently collected data. Objective Our aim is to present real-world objective data on user engagement with popular mental health apps. Methods A systematic engine search was conducted using Google Play to identify Android apps with 10,000 installs or more targeting anxiety, depression, or emotional well-being. Coding of apps included primary incorporated techniques and mental health focus. Behavioral data on real-world usage were obtained from a panel that provides aggregated nonpersonal information on user engagement with mobile apps. Results In total, 93 apps met the inclusion criteria (installs: median 100,000, IQR 90,000). The median percentage of daily active users (open rate) was 4.0% (IQR 4.7%) with a difference between trackers (median 6.3%, IQR 10.2%) and peer-support apps (median 17.0%) versus breathing exercise apps (median 1.6%, IQR 1.6%; all z≥3.42, all P<.001). Among active users, daily minutes of use were significantly higher for mindfulness/meditation (median 21.47, IQR 15.00) and peer support (median 35.08, n=2) apps than for apps incorporating other techniques (tracker, breathing exercise, psychoeducation: medians range 3.53-8.32; all z≥2.11, all P<.05). The medians of app 15-day and 30-day retention rates were 3.9% (IQR 10.3%) and 3.3% (IQR 6.2%), respectively. On day 30, peer support (median 8.9%, n=2), mindfulness/meditation (median 4.7%, IQR 6.2%), and tracker apps (median 6.1%, IQR 20.4%) had significantly higher retention rates than breathing exercise apps (median 0.0%, IQR 0.0%; all z≥2.18, all P≤.04). The pattern of daily use presented a descriptive peak toward the evening for apps incorporating most techniques (tracker, psychoeducation, and peer support) except mindfulness/meditation, which exhibited two peaks (morning and night). Conclusions Although the number of app installs and daily active minutes of use may seem high, only a small portion of users actually used the apps for a long period of time. More studies using different datasets are needed to understand this phenomenon and the ways in which users self-manage their condition in real-world settings.

BackgroundStudies of criteria-based assessment tools have demonstrated the feasibility of objectively evaluating eHealth interventions independent of empirical testing. However, current tools have not included some quality constructs associated with intervention outcome, such as persuasive design, behavior change, or therapeutic alliance. In addition, the generalizability of such tools has not been explicitly examined.ObjectiveThe aim is to introduce the development and further analysis of the Enlight suite of measures, developed to incorporate the aforementioned concepts and address generalizability aspects.MethodsAs a first step, a comprehensive systematic review was performed to identify relevant quality rating criteria in line with the PRISMA statement. These criteria were then categorized to create Enlight. The second step involved testing Enlight on 42 mobile apps and 42 Web-based programs (delivery mediums) targeting modifiable behaviors related to medical illness or mental health (clinical aims).ResultsA total of 476 criteria from 99 identified sources were used to build Enlight. The rating measures were divided into two sections: quality assessments and checklists. Quality assessments included usability, visual design, user engagement, content, therapeutic persuasiveness, therapeutic alliance, and general subjective evaluation. The checklists included credibility, privacy explanation, basic security, and evidence-based program ranking. The quality constructs exhibited excellent interrater reliability (intraclass correlations=.77-.98, median .91) and internal consistency (Cronbach alphas=.83-.90, median .88), with similar results when separated into delivery mediums or clinical aims. Conditional probability analysis revealed that 100% of the programs that received a score of fair or above (≥3.0) in therapeutic persuasiveness or therapeutic alliance received the same range of scores in user engagement and content—a pattern that did not appear in the opposite direction. Preliminary concurrent validity analysis pointed to positive correlations of combined quality scores with selected variables. The combined score that did not include therapeutic persuasiveness and therapeutic alliance descriptively underperformed the other combined scores.ConclusionsThis paper provides empirical evidence supporting the importance of persuasive design and therapeutic alliance within the context of a program’s evaluation. Reliability metrics and preliminary concurrent validity analysis indicate the potential of Enlight in examining eHealth programs regardless of delivery mediums and clinical aims.

IntroductionRecent evidence suggests that text messaging may help to reduce problem drinking as an extension to in-person services, but very little is known about the effectiveness of remote messaging on problem drinking as a stand-alone intervention, or how different types of messages may improve drinking outcomes in those seeking to moderate their alcohol consumption.MethodsWe conducted an exploratory, single-blind randomized controlled pilot study comparing four different types of alcohol reduction-themed text messages sent daily to weekly drink self-tracking texts in order to determine their impact on drinking outcomes over a 12-week period in 152 participants (≈ 30 per group) seeking to reduce their drinking on the internet. Messaging interventions included: weekly drink self-tracking mobile assessment texts (MA), loss-framed texts (LF), gain-framed texts (GF), static tailored texts (ST), and adaptive tailored texts (TA). Poisson and least squares regressions were used to compare differences between each active messaging group and the MA control.ResultsWhen adjusting for baseline drinking, participants in all messaging groups except GF significantly reduced the number of drinks consumed per week and the number of heavy drinking days compared to MA. Only the TA and GF groups were significantly different from MA in reducing the number of drinking days. While the TA group yielded the largest effect sizes on all outcome measures, there were no significant differences between active messaging groups on any outcome measure. 79.6% of individuals enrolled in the study wanted to continue receiving messages for an additional 12 weeks at the end of the study.DiscussionResults of this pilot study indicate that remote automated text messages delivered daily can help adult problem drinkers reduce drinking frequency and quantity significantly more than once-a-week self-tracking messages only, and that tailored adaptive texts yield the largest effect sizes across outcomes compared to MA. Larger samples are needed to understand differences between messaging interventions and to target their mechanisms of efficacy.

Although additional studies are needed, DPT holds promise as a potentially scalable evidence-based treatment of children with disruptive behaviors that can save human resources.