Monday, November 30, 2020

James COYNE's COLUMN

The Benefits of Using Wellness Apps Are Likely Exaggerated, False, or Unproven

What if using a wellness app only provides you with a placebo experience?

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The stronger the claims that using a wellness app meaningfully changes your life, maybe the more you should be skeptical — or the more you should ask to see the evidence.

After all, two of the most robust findings in psychology are that it is difficult to change entrenched habits and it is difficult to maintain any gains without slipping back into old ways.

It is much easier to manipulate someone’s momentary sense of wellbeing than it is to influence objective measures of their health and functioning for the longer term.

By the end of this article, you will understand why you should be skeptical about the impressive claims from promoters of the apps like the Happify app that “86% of the users showed an increase in their happiness score after 8 weeks of regular use.”

You will also see evidence that marketers of wellness apps undoubtedly knew ahead of time that a large-scale randomized controlled trial (RCT) could not possibly show that the average person will get significant benefits from using a wellness app.

Who cares if wellness apps are not an effective means of lasting self-improvement?

Not everybody using a wellness app expects a profound difference in their lives. The common criticism of apps is that they mainly appeal to the worried well, people who are relatively free of distress or impaired functioning. This can become a defense of their use as being harmless. What you see — or feel — is what you get in using an app and that ought to be proof enough.

Wellness apps are exquisitely engineered to be engaging and fun and to provide a sense of social connection. Regardless of whether apps actually succeed in delivering those experiences to most consumers, there are worse things that you could be doing with their time.

On a subway platform or inflight on an airplane, you can usually find some people absorbed with their wellness apps. It would be obnoxious if a loudspeaker blared:

“Attention please. This is a public service announcement. Science says that there is no evidence of an upward spiral of positive change if you keep using that app. Enjoy your placebo experience until the effect quickly wears off.”

When evidence matters.

Matters are different when wellness apps are promoted as evidence-based approaches to self-change, as treatments that are effective in improving users’ mental and physical health.

That is the point at which we should ask to see the evidence.

One of the selling points of apps is that their use approximates the benefits of seeing a coach or fitness trainer or therapist or other health care professional, but apps are cheaper and more convenient. Apps do not involve a long waiting time for an appointment. Does an app really eliminate the need for seeking other help?

Besides wasting money on a paid subscription, relying on an app that is ineffective for someone’s more serious purposes can delay or discourage them from accessing approaches with more established benefits.

At some point, the promotional campaigns for almost all wellness apps veer into false claims about building the immune system or reducing the toll of chronic physical disease.

Reaching for an app may be an alternative to accepting yourself for who you are. Relying on an app that is not capable of producing a significant change in your life may compound your sense of inadequacy, especially when the impression is created by publicity suggesting great benefits being easily realized by everyone else.

Pursuing self-improvement has increasingly become an obligation, not a choice, but a duty to yourself and those with whom you have relationships. You might find a need to find evidence that it might be ok to just say no to this coercion, whether the pressure comes from yourself or other people in your life.

Unpacking claims and evaluating claims that the design of apps is science- or evidence-based

Along with the celebrity endorsements and testimonials of satisfied users, most wellness apps are promoted with claims of being based on solid, established scientific findings. Such claims need to be unpacked and looked at carefully.

Bringing you the benefits of mindfulness and meditation.

Meditation apps like Calm and Headspace claim the support of a large body of research that consistently shows the benefit of meditating. These apps incorporate elements of meditation and give an opportunity to practice when it is convenient and aim to convince you this is evidence-based because the evidence for meditation is solid.

There is a huge literature concerning the effects of meditation and mindfulness on mental and physical health, but most of the studies are surprisingly not very impressive or persuasive.

comprehensive systematic review and meta-analysis prepared for the US Agency for Healthcare Research and Quality (AHRQ) identified 18,753 citations and found only 47 trials (3%) with 3515 participants that included an active control treatment, rather than waiting list or no treatment. There was moderate evidence for improved depressive symptoms and anxiety, but the effects were small and dipped down into the range of trivial effects. Furthermore, there was

low evidence of improved stress/distress and mental health-related quality of life. We found low evidence of no effect or insufficient evidence of any effect of meditation programs on positive mood, attention, substance use, eating habits, sleep, and weight. We found no evidence that meditation programs were better than any active treatment (ie, drugs, exercise, and other behavioral therapies).

The review article was accompanied by an editorial which raised the question:

Why, in the absence of strong scientifically vetted evidence, meditation in particular and complementary measures, in general, have become so popular, especially among the influential and well educated?…What role is being played by commercial interests? Are they taking advantage of the public’s anxieties to promote the use of complementary measures that lack a base of scientific evidence? Do we need to require scientific evidence of efficacy and safety for these measures?

Despite thousands of studies, we don’t yet have convincing evidence that practicing mindfulness or meditating is better than investing the time in some other activity that has other benefits.

I took a look at a study that randomized participants in receiving free training in either meditation or tango lessons. The study was too small and the results were ambiguous, but it was a step in the right direction. A larger study contrasting training in meditation with dance lessons or some other interesting activity might give consumers some answers to questions that they might reasonably have.

We don’t know if the effects practitioners experience are due to nonspecific factors like positive expectations, attention, or social support — i.e., meditating is much more than a ritualized placebo.

Even if the benefits of meditation are mainly a matter of placebo, does an app leave out some conditions necessary for obtaining the placebo effect that would be gained from meditation?

Apps like Happify incorporate modules for mindfulness meditation, but they also claim they have ingredients from evidence-based cognitive behavior therapy and from what the Happify promoters consider the solid science of positive psychology.

The website for Happify claims that it contains “the most important findings from the latest research on positive psychology, CBT, and mindfulness. All in one place, for the first time.”

Fighting depressive symptoms with cognitive behavioral therapy (CBT).

Cognitive behavior therapy has strong evidence as a treatment for the clinical condition, major depression. The quality of the best of randomized trials of CBT rivals the quality of the trials that pharmaceutical companies used to win the approval of the US Food and Drug Administration (FDA) for advertising the effectiveness and safety of antidepressants. Pharmaceutical companies had some guidelines from the FDA for conducting and reporting a clinical trial, and promoters of CBT followed these guidelines

Apps like Happify include modules based on Aaron Beck’s CBT for depression. Can the promoters of positive psychology apps simply rely on the evidence for the efficacy of CBT for the claim that the app “works”?

Not really, for lots of reasons. CBT has detailed treatment manuals that guide therapists in what needs to be done when and what to do when therapy gets stuck. That manualization is not incorporated into the apps.

CBT also provides a therapeutic relationship in which the therapist and patient work together, what Dr. Beck calls “collaborative empiricism.”

That is a fancy way of describing how therapists do not argue against a depressed patient’s pessimism and other negative thinking. Rather, when the patient expresses pessimism about being able to make changes, the therapist and patient negotiate an experiment, homework assignment, to find out if the patient’s negative outlook may actually be valid. The patient tests out this pessimism in their everyday life and then in the next session reports to the therapist what happens and they have a conversation about whether the patient should re-evaluate their negative views or try some more experiments.

One of the many shortcomings of wellness apps is that they do not provide such a human relationship, only a menu with some suggested options. There is not much opportunity for a user to express pessimism or signal that they are struggling and get some support. I Googled <negative thoughts Happify> and up popped some fun instructional YouTube videos. It was engaging and fun, but I am not sure many users would find it satisfying if they were truly suffering in their struggle with negative thoughts.

Fortunately, most users of apps do not have clinically significant levels of depressive symptoms. That is good because apps are not intended to be a replacement for psychotherapy.

Actually, on average, persons who are just starting to use an app will have lower levels of depressive symptoms than what patients are left with who are considered improved at end of a clinical trial.

Depressive symptoms reported at the first assessment with the Happify app will generally fall within the normal range of variations in the mood of everyday life and may represent just a normal reaction to stressful events. But if so, this presents a major challenge for any hope that the average user of an app will experience a significant reduction in depressive symptoms. Users start too low a level of depressive symptoms to experience a significant improvement. That is called a floor effect: they are too low to go lower. Persons at similarly low levels of depression who do not use the app are likely to experience similar reductions due to regression to the mean. i.e, a natural decline to their baseline levels.

Wellness apps as applications of the science of positive psychology.

Over the past decade, I have spent considerable time evaluating the science of positive psychology. Like others from outside of positive psychology, I find the best of systematic reviews and meta-analyses of positive psychology interventions do not meet the minimum standards we expect of other reviews of psychotherapy and behavior change in terms of how to conduct and report a review. I have had a similar experience with RCTs of positive psychology, many of which are web-based studies in which the manipulation considered intervention and the subjective rating scale outcome measures bear little relation to real-world behaviors or their likely consequences.

The Happify website offers links to a huge amount of research supposedly backing strong claims that taking up particular games and activities will produce transformative effects. It is impossible for the casual visitor to the site to determine the strength of evidence for most recommended activities. Many recommendations never were supported by credible studies and other recommendations are based on discredited exaggerated claims, like for Amy Cuddy’s power posing raising women’s testosterone levels so they can succeed in job interviews.The claims for the benefits of positive psychology on the outcome of chronic and catastrophic physical illness would invite a crackdown by the FDA if they were made for herbal supplements or medical devices.

Are wellness apps “science-informed”?

Artwork by Damien Hirst (Source: Wikipedia)

Wellness apps of all brands claim they are science-informed. What could that possibly mean? Certainly, we can find little or no signs of indications or counterindications or recommended doses and intensity of activities based on credible scientific studies.

Perhaps wellness apps could be advertised as science-inspired in the sense that Damien Hirst’s title “The Physical Impossibility of Death in the Mind of Someone Living” is an obvious fit to his artwork. I am afraid that would be a stretch.

Why we cannot expect an RCT to show that wellness apps are an effective means to reduce depressive symptoms and increase resilience.

My last article on Medium was a painstaking analysis of a large scale RCT billed as providing the first evidence of the efficacy for the Happify. I suggested that the RCT was something less than a null trial because it was the product of the inability to retain most of a large number of participants randomized to receive the premium version of the app.

RCTs particularly should be designed on the basis of preliminary data of some kind. The backers of the Happify app, with their extensive monitoring of use of the app should have advised that it would be impossible to retain any more but a minority of the participants enrolled in the study. As with almost any free or commercially available wellness app, most persons who take it up will abandon use before any benefits could conceivably accrue.

Probing the claim that “86% of the users showed an increase in their happiness.”

As with some of the popular meditation apps, claims are made that most users of Happify will experience an increase in happiness. What could that possibly mean, given the large number of persons taking up the app but stopping after only minimal usage?

The estimate is based on a highly select, non-representative, and small minority of users who persist in using the app with some minimal frequency deemed necessary to gain a benefit. We can ask percent of what? Certainly not of people taking up the app. The estimate excludes the majority of people taking up the app who quickly gave up on using it, for whatever reason. Given the circumstances in which 86% was obtained, there can be no confidence that if people did not abandon the use of the app, they would become happier.

Perhaps the most robust, science- and an evidence-based statement that can be made about wellness apps is

“Few people who take up this app will persist long enough to obtain benefit. If you are not getting benefit from using this app, there is no guarantee that using it longer or more frequently will give any better results.”

I doubt that we will see promoters of apps making this disclosure anytime soon.

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James Coynehttp://www.coyneoftherealm.com
James C. Coyne is Professor Emeritus of Psychology in Psychiatry at the University of Pennsylvania where he was Director of Behavioral Oncology at the Abramson Family Cancer Center and Senior Fellow, Leonard Davis Institute of Health Economics. He also was Professor of Health Psychology at the University of Groningen, the Netherlands, and has been on the faculties of University of Michigan School of Medicine and University of California, Berkeley. He received a BA in Psychology from Carnegie Mellon in 1969 and a Ph.D. in Clinical Psychology from Indiana University in 1975. Professor Coyne was the 2015 Carnegie Centenary Visiting Professor at the University of Stirling. He is the author of over 400 articles and chapters and has been designated one of the most influential psychologists of the second half of the twentieth century. His diverse interests have included clinical health psychology, mental health services research, and evaluation of depression screening and suicide prevention programs. As a blogger at Science-Based Medicine and Mind the Brain, Dr. Coyne is known for skeptical appraisals of advice gurus misleading consumers with hype and hokum. His activism with colleagues concerning undisclosed conflicts of interest has yielded dozens of corrections to published papers, a few retractions, and the Bill Silverman Prize from the Cochrane Collaboration.

JAMES COYNE, PHD

James C. Coyne is Professor Emeritus of Psychology in Psychiatry at University of Pennsylvania where he was Director of Behavioral Oncology at the Abramson Family Cancer Center and Senior Fellow, Leonard Davis Institute of Health Economics. He also was Professor of Health Psychology at University of Groningen, the Netherlands and has been on the faculties of University of Michigan School of Medicine and University of California, Berkeley. He received a BA in Psychology from Carnegie Mellon in 1969 and a PhD in Clinical Psychology from Indiana University in 1975.

Professor Coyne was the 2015 Carnegie Centenary Visiting Professor at the University of Stirling. He is the author of over 400 articles and chapters and has been designated one of the most influential psychologists of the second half of the twentieth century. His diverse interests have included clinical health psychology, mental health services research, and evaluation of depression screening and suicide prevention programs. As a blogger at Science-Based Medicine and Mind the Brain,

Dr. Coyne is known for skeptical appraisals of advice gurus misleading consumers with hype and hokum. His activism with colleagues concerning undisclosed conflicts of interest has yielded dozens of corrections to published papers, a few retractions, and the Bill Sliverman Prize from the Cochrane Collaboration.

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