Study results suggest that while many academic apps have been developed to support people with schizophrenia, very few suitable apps are actually available for use today. The situation is related to the commercial marketplaces where hundreds of apps are returned in searches but there are less than ten that are accessible and clinically relevant. Despite impressive research efforts, people with schizophrenia are today able to access a paucity of apps. A focus on translating research efforts into accessible apps should become the priority for the field.
We identified sixty unique apps used in schizophrenia research. Of these 60 apps, 31 (51.7%) were not available at all meaning that it is challenging to replicate or expand on their results. This result is perhaps not surprising given the challenges and costs associated with maintaining apps. For example, Krzystanek, a developer of MONEO app included in the results,50,51 explains “the investor who wanted to commercialize it [the MONEO app] wasn’t up to the task, so the project was suspended.”127 However, our results do suggest one potential solution as we found that apps developed on non-specific platforms were significantly more available today than those created on customized app platforms (χ2 = 4.241, p = 0.039). While a customized app offers clear advantages, using a broader platform may offer a more rapid and sustainable approach, especially for early phase work.
While there are many reasons a research app may not be available for easy public use, our result that 20 (33.3%) were also not accessible as they required an access code is notable given the goal of most apps is to increase access to care. While our results cannot directly support why, it is likely that these apps themselves are necessary to use in concert with a care program and not as standalone self-help tools. Using apps to augment care can certainly help increase access to care, but raises the need for concomitant training, workforce, implementation, and clinical infrastructure to support scalability. In reviewing the relevant literature, we found such documentation was often lacking although it represents an important target for new and ongoing app efforts.
A few, nine (15.0%), research apps were available to download and directly use. However, these results must be interpreted with caution as only 2 of these 9 apps was created on a schizophrenia specific platform43 and the other 7 on non-specific app platforms. Examples of non-specific platforms include WeChat, MovisensXS, and mindLAMP (developed by the authors) meaning that a patient or clinician would need to customize or add content to the platform for it to be ready for clinical use. This may often involve a licensing fee depending on the app or at least some degree of technical knowledge, reflecting a further barrier to access.
While there is room to improve accessibility of research apps, our results suggest this work is necessary as the current marketplace offerings are concerning. After an exhaustive search of apps on the iTunes and Android stores, we found only 25 psychosis-specific marketplace apps from the 537 our search revealed. Of these 25 apps, only six were deemed clinically appropriate with the other 19 offering inaccurate, outdated, stigmatizing, or inappropriate content. For example, one app tells users to “remember that it’s [schizophrenia] all in your head.”128 Two apps recommend “St John’s Wort [which] works as an antidepressant in patients with schizophrenia disorder”129,130 as a part of the home remedies without clear warnings of dangerous medication interactions.131 Three apps offered psychoeducation about “Disorganized, Catatonic and Undifferentiated schizophrenia”132–134 which have been removed from the DSM-5 for over five years.135
Considering the six (1.1% of 537 marketplace app) that were deemed clinically appropriate, five solely provided information/psychoeducation, and only one app included therapeutic and monitoring features. However, all six apps are not currently updated with an average time since last updated being 1121 days (3.07 years ago)- well exceeding the 180 days update metric adopted by the American Psychiatric Association, which prompts a concern for an app quality and safety.136 Of note, while these apps were not updated recently, the psychoeducation they provided was so general that the content was not out of date. Still, considering that these are the apps most readily accessible to people with schizophrenia today it is clear that the potential of apps to increase access to care has yet to be fulfilled.
Our results suggest clear and tangible next steps. For research to accelerate to increase access to care, it is necessary to either build apps on non-specific platforms or to make apps built on specific platforms directly available for people to use. While advanced apps are being studied, there is a clear need to provide simple but up to date apps directly on the Apple and Android marketplaces so that people with schizophrenia can at least benefit from higher quality psychoeducation and app offerings.
Our results also suggest a broader question around when an app is necessary for schizophrenia specifically versus when a more transdiagnostic app will suffice. For example, medication tracking is a common feature across nearly every health condition and the added value of a schizophrenia specific vs general mediation tracker remains an open question. Similarly, apps which help support people to engage in regular physical activity, adopt healthy eating patterns, quit smoking or even or manage common physical health conditions such as type-2 diabetes are theoretically just as important (or more so) for use in schizophrenia as the general population.137 In our team’s work with the MIND website which evaluates apps, we often find ourselves helping people create toolkits of apps that utilize useful features across a range of apps to create the right set of resources for each patient. Research onto a common or transdiagnostic set of app functions for mental health, including schizophrenia, could help focus schizophrenia research on the unique challenges of the field and avoid unnecessary duplication of work.
Our findings expand on prior research results that support our results. Prior studies from our team have examined the top 10 apps for schizophrenia and found similar results,136,138 but those studies did not exhaustively search for every app as we did here. Another review found that the number of commercially available apps with academic evidence from across all health fields is scarce but did not focus on schizophrenia and is based off older 2017 data.139 Our results complement past reviews of research apps for people with schizophrenia15,16 that also found few available for patients although here we found nearly twice the number of research apps as compared to prior studies – perhaps reflecting accelerating interest in this space.
Like all reviews, ours has several limitations. We only search for research papers in English and are aware that given the many diverse names used to characterize this research, our search term may have missed some studies. However, a primary purpose of the review was to gain an assessment of the extent to which apps in readily-accessed research studies are aligned with those widely available on the marketplace, and there is no reason to believe that any missed studies more difficult to identify would reveal a preponderance of research apps in a way that would change our results. Our marketplace search was exhaustive, but we also realize searches from different regions (ie outside of the United States) may yield different results such as emerging work from China.140 A search with more keywords may have results in more included apps but given only 1.1% of the returned results were relevant, we felt our search was already comprehensive.