Sci-tech

OP-ED

The techno-utopian fantasy that apps will magically solve teens’ mental health problems is unfounded

The techno-utopian fantasy that apps will magically solve teens’ mental health problems is unfounded
(Photo: Unsplash / Pier Monzon)

There is growing concern about the mental health of adolescents. Increasing young people’s access to effective, affordable, and acceptable treatments for mental disorders like depression and anxiety is a pressing problem with no easy solutions.

In the past decade rapid expansion in the development of mental health apps has been accompanied by a great deal of techno-hype about how digital solutions will revolutionise and democratise mental healthcare. Techno-optimists imagine a technological utopia in which everyone magically and effortlessly has access to affordable and effective mental healthcare on demand and from anywhere at the touch of a button.

Apps certainly have the potential to increase access to high-quality mental healthcare, especially for adolescents. Having grown up in technology-rich environments, young people are comfortable using digital technologies and are open to the idea of receiving psychological help online.

It is estimated that more than 85% of the world’s population owns a smartphone, and it is enticing to imagine how these devices might be used to put mental healthcare in the hands of everyone who has a smart device. Entrepreneurs have already seen the potential of digital solutions to mental health problems and in 2018 there were more than 22,750 apps in iTunes and Google Play stores claiming to improve mental health.

But has the plethora of mental health apps had any discernible impact on adolescent mental health? It is hard to find evidence at a population level that the proliferation of mental health apps has led to marked improvements in adolescent wellbeing. If anything, mental health outcomes globally keep worsening even as access to digital treatments increases, a phenomena known as the digital mental health paradox.

Dr John Torous, director of the digital psychiatry division at Harvard Medical School, describes two hypotheses that could explain the digital paradox.

The “harm hypothesis” postulates that any potential benefits from access to mental health apps have been offset by the harmful effects of living in an increasingly digital world.

The “illusion of innovation” hypothesis contends that apps are basically ineffective because of a lack of real innovation and because most apps either do not work or are simply not engaging enough to retain users.

Supporters of the harm hypothesis argue that the consequences of living in a technology-rich environment (such as excessive screen time and social media use) are so toxic to wellbeing that they displace any potential benefits from increased access to mental health apps.

But are social media and screen time really so detrimental to mental health? Before prescribing apps to adolescents with mental health problems we need to understand the potential psychological harms of digital technologies.

Recent high-quality studies suggest that for most people social media use and screen time have minimal impact on mental health. However, most studies focus narrowly on adults, have only investigated correlations (not causation), and have failed to identify any consistent or large positive effects.

Although large-scale rigorous studies on adolescents have found small positive associations between poor mental health and duration of daily technology use, they do not distinguish cause from effect and thus cannot explain if poor mental health causes adolescents to spend more time using digital technologies, or vice versa.

It is certainly true that for some vulnerable teenagers, social media use can have serious mental health consequences, and there is a need for rigorous research to understand which adolescents are at risk, why they are at risk, and what can be done to ameliorate risk.

It is too simplistic to say that social media and screen time are equally harmful for all adolescents. To understand the impact of technology on mental health we need a life course perspective, which acknowledges that psychological vulnerability is heightened at specific periods of development.

A longitudinal study of 17,409 adolescents aged 10-21 years old found clear developmental windows of sensitivity to harmful effects of social media use. For males these windows of sensitivity occur at 14-15 and 19 years old, while for females the windows occur at 11-13 and 19 years old.

Supporters of the lack of innovation hypothesis argue that we have not seen marked benefits from mental health apps because a lack of any real innovation in app development has created serious problems with poor uptake and low levels of sustained use. The uptake of mental health apps has certainly been slow, mostly because of concerns about privacy and scepticism about effectiveness.

Privacy concerns

Mental health professionals and patients have voiced concerns about privacy, which is unsurprising given the clear evidence of blatant privacy violations by some app producers. A study of popular apps for depression and smoking cessation available in app stores found 81% of apps transferred users’ private data to Facebook or Google, but only 41% disclosed this in their privacy policy.   

Aside from privacy concerns, do mental health apps even work?

A systematic review of mental health apps found that while some studies showed potential to reduce symptoms, there was not enough evidence in 2018 to support using apps as stand-alone treatments. Subsequently there have been more studies showing apps’ effectiveness at reducing symptoms, although not all these studies are very rigorous.

In 2022, a systematic meta-review of 14 meta-analyses of randomised control trials to test mental health apps found that most studies were of poor quality. Instead of testing if apps work as well as other conventional treatments, many studies compare mental health apps to nothing, and then conclude that something is better than nothing. When it comes to the mental health of the country’s youth, “better than nothing” is not a good enough standard.    

When assessing apps’ effectiveness, it is also important to differentiate between apps that effectively treat mental disorders and apps that can help people tame the uncomfortable feelings which are a normal part of everyday life. Saying that an app can help people relax is not the same as saying it can treat anxiety disorders.

Techno-fixes

Before we become too gung-ho about apps, it is important to think about what we are doing and implying when we advocate for techno-fixes to mental health problems.

Three assumptions (which may not be true) underlie the use of mental health apps. First, individuals should be responsible for fixing their own mental health problems. Second, each of us is competent to manage our own mental health without the direct help of professionals. Third, the “problem” we are trying to fix is located within individuals.

In other words, in advocating for apps as stand-alone treatments for mental disorders we imply that each of us has control of our own mental health and that to be a good responsible citizen we should take responsibility for ourselves.

Such an approach reproduces a neoliberal worldview and feeds the growing public health trend towards individualisation of responsibility (ie shifting responsibility for health from social institutions to private individuals), thus letting the government off the hook.

Decades of research on social determinants of health have made it patently clear that aside from being a function of individual characteristics and internal processes, psychological wellbeing is also shaped by socio-political and economic forces outside the individual.

Unfortunately, no digital technology, smart gadget or machine learning algorithm will solve the disparities, inequalities, and socioeconomic problems which contribute to poor mental health. It is horribly misguided to think that technology could deliver us from social problems like racism, ableism, sexism, classism, and bullying which compromise mental health.

The techno-utopian fantasy that digital solutions will magically solve adolescents’ mental health problems is unfounded. Digital technologies undoubtably hold much promise to increase access to treatment and reduce some symptoms of psychological distress, but unfortunately it seems unlikely, at least for now, that apps can be used on their own to treat mental disorders.

To realise the full potential of technology, we need rigorous research on mental health apps’ effectiveness, creative strategies to safeguard users’ privacy, and well-designed technologies that promote uptake and sustained use.

Importantly, we also need mechanisms for helping people sort through all the techno-junk to find apps that are safe and effective. DM

Prof Jason Bantjes is a chief specialist scientist in the Alcohol, Tobacco and Other Drug Research Unit at the South African Medical Research Council. He also holds an extraordinary appointment at the Institute for Life Course Health Research at Stellenbosch University and is an honorary professor in the Department of Psychiatry and Mental Health at UCT.

This is an abridged version of a speech delivered at the recent SA Mental Health Conference.

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