Choosing the Right CBT App for Depression and Anxiety

PURPOSE

• Patients report that the app is well-structured and useful for tracking negative thoughts.
• The app is best to use with patients with well-managed mild anxiety or mild depression.

APPROPRIATENESS OF CONTENT

• Although, I was not able to find clinical trials demonstrating the effectiveness of the Sanvello app specifically, there is a large amount of scientific data that supports the use of CBT for depression and anxiety and also substantial scientific support for the mindfulness and healthy behavior aspects of the app.
• The app offers a module with techniques to deal with anxiety and depression, with the goal of better managing moods and emotions. The app also includes a series that incorporates CBT techniques to help set goals, identify negative thought patterns and find strategies that might help with depression symptoms by encouraging users with techniques geared toward changing interpretation of thoughts, beliefs and experiences.
• There is a mindfulness module along with meditation activities, a daily health tracker for exercise, sleep and caffeine consumption and what they call a “hope board” (similar to a vision board)  that patients can use to collect quotes, photos and other completed activities.
• The Sanvello app uses progress assessments to show connection points between experiences, activities and emotions so people can see what happened, how they felt and how to adapt future behaviors.
• Sanvello has an online peer support community where users are assigned anonymous user names and can give/get encouragement from others. Clients can post comments on any of 15 communities and chat groups and get comments and feedback (similar to FaceBook) from other Sanvello users. A sample of the group themes include: Anxiety, work stress, relationships, health and school stress.

CULTURAL RESPONSIVENESS

• It does not appear that the app can be modified for or extended for children and preteens. The age rating is 12+ for the following reasons: infrequent/mild medical/treatment information.

EASE OF USE

• The meditations can be downloaded for people who may not have access to internet although it does not appear that other content on the app can be used without internet.
• Regular reminders and feedback through app notification and emails are included.

FUNCTIONALITY

• Sanvello costs $8.99 a month or $53.99 yearly, or $200 dollars for a lifetime account.

FINAL THOUGHTS

Sanvello is based on psychological practices and principles: cognitive-behavioral strategies such as challenging distorted or all or nothing thinking, negative cognitions and catastrophizing. The mindfulness activities, visualizations, behavior tracking, goal-setting and peer support are all psychologically based strategies and tools that when used along with appropriate monitored mental health treatment from a licensed provider of services could be helpful for clients to use between sessions in collaboration with their mental healthcare provider.

PURPOSE

• The application is not a treatment for any disorder nor is it a substitute for professional treatment.
• At initial setup (on-boarding) users are prompted to select three goals from eight different options. Then the application will prompt users once a day to rate their mood on a scale ranging from awful to great. Users have the option to provide additional feeling/emotion description from a pull-down list.
• Users receive interventions/tools suggestions to improve their mood based on ecological momentary intervention.
• Sanvello for Behavioral Health Clinicians currently does not appear to work but is advertised to: provide HIPPA compliant services including sending and accessing GAD-7 and PHQ, telehealth services, scheduling, assigning homework and messaging.

APPROPRIATENESS OF CONTENT

• Video content is done by Kati Morton a licensed marriage and family therapist and certified DBT, behavioral therapist and grief counselor. No information regarding Morton’s credentials, expertise, was provided on the application. No information regarding formation of content by clinical psychologists or therapists was provided.
• The application lists research that was reviewed in the development of its content and support its marketing of empirically and scientifically grounded interventions.
• The application has one research trial that suggested that users who interacted more with the application had improvements in mood and anxiety symptoms at a two-month follow-up after using the app for one month. Those who indicated they were taking psychotropic medications reported less benefit from the app. Additional research is needed given the study was primary and the company has switched from Pacifica and services are changing.

CULTURAL RESPONSIVENESS

• There is no varying ability levels or specific information regarding how the application considered of age, race, ethnicity, gender, gender identity or sexual orientation.
• The application follows guidelines for children under age 13 accessing the application; however, the content seems more geared towards early adulthood and beyond.

EASE OF USE

• App offers multiple areas for customization in goal and tracking.
• Data is tracked and stored; however, user also has the option to delete all of their data. Deleted information cannot be restored.

FUNCTIONALITY

• The application provides play lists through Spotify; however, it is glitchy and while songs will play, the application repeatedly directs the user to open a web browser making it impossible to engage with Spotify.
• Sanvello for Behavioral Clinicians offers a free 30 day trial and provides an overview of services offered; however, even after filling out the form and paying for content I was not able to get into Sanvello for Clinicians.
• Weekly and monthly reports can only be accessed by computer on Sanvello.com and cannot be accessed via the app.
• Emergency Resources are not clearly identifiable.

FINAL THOUGHTS

Community groups within the app featured diverse topics and communities including LBGTQ+, nontraditional students, veterans, those in the helping professions and public service, to name a few. Communities for those speaking a specific foreign language were also featured. These communities, while unmonitored, used a flagging system and appeared to be supportive — offering suggestions and empathetic and caring responses. Community groups also shared gratitudes, music favorites, movies, quotes and stories, shared which can be helpful to those who feel alone and isolated.

Sanvello recently acquired Pacifica for its platform and ultimately has a bigger vision to include live coaching, teletherapy and coverage by major insurance companies. Through the processes of rebranding and changing functionalities/services, several functions in the application were not working predictably such as terms of agreement/privacy policy and the trial for providers.

PURPOSE

• At on boarding, users are asked to provide a good time of day to check in and then users are prompted  three times a day to answer questions to determine if a user may be experiencing depressive symptoms. The app uses DSM criteria as well as additional questions that are common experiences of those who are experiencing depressive symptoms or emotional burden. The application has undergone several clinical trials since its launch and its algorithms have been able to distinguish between depressed state and clinical depression; although, the application does not make a diagnosis. This assessment is the “moodpath.”
• After 14 days the application sends results to the user results and provides recommendations for action along with a doctor’s letter to share with their primary care, therapist or psychiatrist — either in an on-going care or initial visit.
• Discover: The application provides users with a free course “Understanding Depressive Symptoms” for those who are information seeking regarding their symptoms as this course provides an information regarding criteria used to make the diagnosis as well as treatment recommendations for levels of depression severity. The full subscription provides courses on mindfulness, rumination, self-confidence, emotions and sleep which provide psychoeducation along with written exercises and mindfulness activities based in CBT.
• Insights: Provide users with summary of their recent responses and provide validation, normalization, empathy with recommendation for content on the app, which may be helpful including mindfulness, psychoeducation and CBT interventions.
• Pause: Mindfulness exercises for several areas such as tackling overwhelming emotions, building self-confidence, sleep, morning meditations, conflicts looping thoughts, heartbreak & relationships, calming sounds and developing a positive attitude.
• Users can provide their data from assessment to their provider or provider can initiate contact to a client/patient through the app. This appears to still be in an initial phase with additional software in current development for doctors and psychotherapists.

APPROPRIATENESS OF CONTENT

• Research of the application is “continually being validated” through data gathered from the user as explained in the terms of use. The application does not collect any identifying information from users and the platform is completely anonymous as each user’s data is given a code that connects to the servers. Research regarding Moodpath has been published and at least one article has been accepted for future publication. While using the application, opt-in research consent forms from Columbia University appeared while I was reviewing the application.
• Content is heavily based in readings and audio recordings and to access these areas which may be most helpful a user needs to have a membership.
• Providers are also able to unlock content for their patients/clients through Aurora Health and will need to either send an access code or the user would need to reach out to the therapist. Unfortunately, I could not get this to work when I was reviewing the application.
• The application also provides information for app-based therapy service, Better Help.
• Some of the discovery didactics didn’t go far enough in linking concepts or provide the user ability to review learning. As such, users who are seeking more in-depth treatment may consider Moodpath interventions introductions to psychotherapy treatment which could build and link these concepts and further develop insight.

CULTURAL RESPONSIVENESS

• The application is available in English and German.
• Images on the application are animations or small icons.

EASE OF USE

• Users may delete their information at any time from both their phone and the Moodpath server. 
• Some content can be a bit tough to find and is under different sections than what I thought would be appropriate.

FUNCTIONALITY

• Crisis services directed callers to the “telefonseelsorge” under Therapy Options and not Crisis Services. The app did not clearly identify that users would be connected to the National Suicide Hotline rather has it as the Mental Health Hotline. It was hard to find this area in the phone and was under insights and in the settings tab.

FINAL THOUGHTS

I would recommend this app, especially when beginning work with clients who may be experiencing depressive symptoms as it was helpful to discuss their tracked mood states as well as the context and related thoughts. I found that clients seemed much more aware and engaged in the additional readings found on the app. During sessions, we would review their Moodpath as a launching to the session and discussion of homework. I found Moodpath to be an appropriate adjunct to treatment/homework provided in psychotherapy. Mindfulness exercises, while brief, seemed helpful to clients, especially when they engaged with the app’s Insight tab and tapped on the resulting recommended content.

PURPOSE

• The app includes some educational materials about things like CBT, Mindfulness CBT and ACT, along with basic descriptions about things like psychotherapy. It also direct users to an online therapy option and has an emergency function.
• In addition, there are repeated assessments of mood. The app prompts the user every day to complete “journal” questions that address symptoms of negative mood and provide a general single mood identification (presented with both an icon and a word).
• The general approach in almost all the audios’ is the use of relaxation strategies as a method to improve staying present. Most of the audios use breathing or muscle relaxation to initiate mindfulness through directives like “look into yourself.” The reliance on focused breathing as a key strategy to promote attention to experiences and environmental experiences is not as likely to help users to manage their depression and anxiety as would integration of other evidence-based CBT strategies.

APPROPRIATENESS OF CONTENT

• The language in the content is sometimes a bit more complex than what some users would need, and there are occasional phrases describing emotions that this reviewer believed risked making users negatively about experiencing the emotions.
• One aspect of the app’s assessment protocol, the repeated request to complete assessment questions each day, became annoying since the timing was app generated when this reviewer used it. The prompts could be experienced as intrusive, and it is unlikely that most users will comply with or benefit from this daily assessment strategy.
• It is unclear if any clinical or psychology experts helped develop Moodpath. Given the reliance on ACT and mindfulness, it is easy to infer that ACT experts contributed at some level.

CULTURAL RESPONSIVENESS

• The language used in the audios is somewhat high level, sometimes even using complex psychological jargon that is defined. Such language might be hard to interpret by those from other cultures.
• While the gender option appeared to rely on binary gender identities and did not seem to provide other options, the relationship audio did not presume a single sexual orientation or gender identity and appeared culturally sensitive.
• Given the reliance on ACT and mindfulness, Moodpath may not be as culturally relevant to some as it might be to others. For example, Raphiphatthana, Jose and Chobthamkit (2019) point out that cultures that have more in common with individualistic cultures when compared to collectivist cultures. Woods-Giscombe and Gaylord (2014) point out that mindfulness may need some “minor” modifications in order to be more culturally relevant to African Americans.

EASE OF USE

• While a section in the home screen is available to write down thoughts, it was not clear in any instructions what the purpose of doing so was.

FUNCTIONALITY

• I did not find any glitches while using either the assessment functions or the audio/written exercises.

FINAL THOUGHTS

Psychologists who practice mindfulness CBT, or who are ACT therapists, would likely find this app very useful for their patients. Other types of more traditional CBT approaches might find it less useful.

I would be concerned that patients would not understand what might happen to their assessment responses beyond the app on their phone. Psychologists would be well served to provide a written informed consent form to patients who use the app as a part of therapy or consultations because of the open research platform and use of data by universities.

PURPOSE

• MoodTools helps individuals track interventions used to address depression symptoms. The variables captured on the app are based on Cognitive Behavior Therapy (CBT) principles and include engagement in activities (with tracking of mood before and after activities) and a thought diary (where you can document negative thoughts and associated emotions and level of distress) cognitive distortions and alternative thoughts.
• Additionally, MoodTools provides users with educational information about depression, treatment options, crisis resources and hotlines, YouTube videos and TedTalks on related content, nature sounds and one therapist directory (i.e., Psychology Today).

APPROPRIATENESS OF CONTENT

• The Thought Diary is helpful in tracking negative thoughts to situations and provides users with the opportunity to generate alternative thoughts to situations to challenge their automatic thoughts. It would be an improvement for users to have the capability to track positive thoughts as well, so that the focus is not only on the negative.
• The Safety Plan is extremely useful feature. Users can  develop the Safety Plan on the phone, and  have it readily available. I strongly recommend that users complete the Safety Plan in conjunction with a licensed/trained mental health professional.
• The app allows clients to take the Patient Health QuestioouPHQ-9 every two  weeks, which is a useful way for psychologists to track changes in their client’s depression symptoms.

CULTURAL RESPONSIVENESS

• MoodTools only links to one Therapist Directory (i.e., Psychology Today). There are a number of Therapists Directories that highlight mental health professionals of color (e.g., Melanin and Mental Health & Therapy for Latinx).

EASE OF USE

• Users can change the preset activities or add their own activities. This allows people to include activities that are relevant to their experience.

FUNCTIONALITY

• You can see the Safety Plan on one page, but you cannot export or download it. The only data that you can export is information from the Thought Diary.

FINAL THOUGHTS

For clients who are experiencing suicidal ideation, the Safety Plan option provides clients with quick and easy access to their plan.

PURPOSE

• The app states at the bottom of the site that it is not a replacement for mental health treatment and yet it doesn’t go far enough to emphasize this within the marketing for the app.
• Psychologists and their clients may find the MoodTools app a helpful tool for outside of therapy sessions in managing symptoms of depression and to have crisis resources in an organized easy to access format.

APPROPRIATENESS OF CONTENT

• I was not able to find any research evidence for the app specifically even though the tools and principles within the app such as CBT techniques and strategies are evidence-based when used clinically.
• Important to note that the content does not appear to be appropriate as a standalone tool without the appropriate care from a psychologist or licensed mental health provider.
• The app also provides an option to access a paid service for telehealth which may be problematic in situations for high risk users or for app users without the financial means to use the telehealth component. It was not clear on how situations of high risk would be addressed by the telehealth therapists or how the telehealth therapists manage referral for patients they are not able to provide services for or take on as clients.

EASE OF USE

• My clients have commented that it was easier to complete thought records and CBT homework between therapy sessions due to the easy access to the information on their phones.
• Clients have also commented that recording their symptoms on the phq9, and the ability to track the severity of their symptoms or watching their progress along with looking back at their notes and journals have been helpful in challenging irrational thinking.

FUNCTIONALITY

• It is nice to have a list of activities to try when clients are feeling down, but the app could be even more effective if it could be customized by each individual and the unique activities that might be helpful for them to employ.

FINAL THOUGHTS

A phone app is not a replacement for professional help, but if used as a tool, the MoodTools app may provide an additional source of support to help manage negative thoughts.