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Inadequacies in mental health care coverage remain an enormous problem in the United States. Barriers include scarcity of accessible mental health care professionals. Use of a mental health mobile app incorporating social cognitive theory may help improve confidence in coping skills and improve anxiety and depression. Sinasprite is a mobile app that recruited users via self-referral and clinician referral. Users completed questionnaires to obtain demographic and medical histories. At baseline and 6-week follow-up, users completed the Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder 7-Item (GAD-7), and the Coping Self-Efficacy Scale (CSE). It is unknown how self-directed use of a mobile app improves confidence in coping skills and its effects on self-reported depression and anxiety.
The objective of this study was to evaluate the Sinasprite database to assess self-directed engagement and how use of this mobile app impacted self-reported confidence in coping skills and severity of depression and anxiety.
This retrospective longitudinal study involved users recruited via clinician referral and self-referral through social media and news media. Questionnaires were used to record demographic, medical, and prescription medication histories. Mental health status was assessed via PHQ-8, GAD-7, and CSE questionnaires. A deidentified dataset reporting mobile app use data was provided to investigators. Individuals with verifiable usage data and at least one completed questionnaire at 6 weeks of use were included. Mann–Whitney
Thirty-four users were eligible for inclusion in the analysis. Users were predominantly female, white, married, and college educated. At baseline, 35% (12/34) of respondents reported the use of individual/group counseling, and 38% (19/34) reported using prescription medications for their mental health. The median user completed 5.7 (interquartile range 2.7-14.1) trackable activities per week. Statistically significant improvements using a Wilcoxon signed-ranked test were observed in the PHQ-8 (
This 6-week retrospective study showed that self-directed use of the mobile app, Sinasprite, resulted in significant improvements in self-reported questionnaire scores reflecting depression, anxiety, and confidence in coping skills.
Approximately 43 million adults in the United States experienced mental illness in 2015 [
Depression and anxiety are ranked the first and sixth global causes of disability, respectively [
Two-thirds of the American population owns a smartphone, thereby presenting an opportunity for health care services that can overcome geographical and financial limitations [
A study by Burns et al demonstrated that a mobile app, which incorporated the use of machine learning, behavioral training, and coaching, was able to assist in the care of patients with major depressive disorder [
Although there are significant published data on the effects of mobile health apps on depression and anxiety, little is known about the effects of these interventions on coping skills and their relationship with the management of depression and anxiety severity. Coping is defined as the behavioral and cognitive efforts individuals use when faced with psychological, emotional, and physical stressors [
Sinasprite is a self-directed mobile app developed using Bandura’s social cognitive theory that includes elements of CBT and mindfulness strategies to improve an individual’s ability to cope with stressors and is expected to decrease the severity of an individual’s anxiety and depression. Litesprite (Bellevue, WA, USA), an organization that develops mental health mobile apps, released Sinasprite in the iOS and Android app stores as a beta (
This retrospective longitudinal study evaluated user engagement and outcomes associated with the use of Sinasprite, a native mobile app developed by Litesprite. Investigators received a deidentified dataset from the mobile app development team containing usage data, questionnaire responses, and demographic data. The Ohio State University Institutional Review Board deemed this study to be exempt from human subject’s research.
This mobile app was developed using Bandura’s social cognitive theory and included elements of CBT and mindfulness-based stress reduction [
The mobile app was released to the public in a live beta to allow users to use and potentially benefit from it with minimal intervention and support from health care practitioners. Anyone aged 18 years or older was invited to use the mobile app. Users were recruited via clinician referrals and self-referral through social media and news media such as Facebook advertisements and presentations and news articles published in
Users were electronically sent access to a secure website where they completed a voluntary questionnaire requesting demographic information, medical history, use of psychotherapy and prescription medications, and mental health status via the Patient Health Questionnaire 8 (PHQ-8) [
Data were organized and coded in IBM SPSS Statistics (v24.0; Armonk, NY, USA) and were assessed for normality using the Wilk-Shapiro test and histograms. All users were included in the initial dataset. Users who did not complete any of the surveys after 6 weeks of use or did not have verifiable usage data were excluded. Due to the low sample size and non-normal distribution of the data, Mann-Whitney
Several indicators were used to evaluate the mobile app. Included were the average length of in-game session, completed meditation sessions, mindfulness paintings, anxiety journal entries, and self-assessment questions. Given the in-development (beta) status of the mobile app, it was not possible to collect data from some modules. These included the fishing module and an augmented reality exercise module that encouraged walking. The weekly amount of user activity was calculated by adding the number of completed activities and dividing by 6 weeks. Although the mobile app was intended to be used several times a week, users were encouraged to use the modules in the frequency they felt will be of most benefit to them. This was intended to allow users to determine their own experience and make use of the app as “nonconfrontational” as possible [
A Spearman rho (ρ) test was used to assess the relationship between improvement in the CSE and GAD-7 and PHQ-8 results. A preliminary analysis using a scatter plot of the results was performed to ensure the relationship between improvements in the questionnaire scores followed a monotonic relationship.
To assess the change in self-reported questionnaire outcomes among users, a Wilcoxon signed-rank test was performed. This test was then repeated with users who reported no concomitant therapies. Cohen
To further evaluate the effects of using the mobile app on mental health, a mixed-effects repeated-measures linear regression model using unstructured variance, restricted maximum likelihood, and intercepts was conducted. This method was chosen because of its superiority to analysis of variance in assessing correlations [
The sample included data from 450 users of the mobile app. However, 275 users were excluded because of lack of verifiable usage data, and an additional 141 were excluded for not completing at least one 6-week follow-up questionnaire (PHQ-8, GAD-7, or CSE). The final sample for the analysis included 34 users (
In this study, users included for analysis were predominantly female 77% (26/34), white 41% (14/34), married 62% (21/34), and college educated 71% (24/34) with a median age of 40 (interquartile range [IQR] 32.75-50.75) years. Moreover, 35% (12/34) of users reported receiving individual or group counseling, and 38% (13/34) reported using prescription medications for their mental health (
Mobile app usage data are presented in
Consolidated Standards of Reporting Trials (CONSORT) flow diagram illustrating exclusion criteria.
Demographic and clinical characteristics of users of Sinasprite mobile app (N=34). Percentages may not equal to 100% because of rounding.
Characteristics | Statistics | |
Age in years, median (interquartile range) | 40 (33-51) | |
Male | 6 (18) | |
Female | 26 (77) | |
Prefer not to say | 2 (6) | |
Did not graduate high school | 1 (3) | |
High school diploma | 9 (27) | |
Bachelor’s degree | 10 (30) | |
Graduate degree | 14 (41) | |
White | 14 (41) | |
Asian | 1 (3) | |
Prefer not to say | 19 (56) | |
Single or never married | 6 (18) | |
Married or partnered | 21 (62) | |
Separated | 2 (6) | |
Divorced | 3 (9) | |
$20,000-$29,999 | 3 (9) | |
$30,000-$49,999 | 2 (6) | |
$50,000-$69,999 | 1 (3) | |
$70,000-$99,999 | 2 (6) | |
$100,000-$149,999 | 2 (6) | |
>$150,000 | 2 (6) | |
Prefer not to say | 22 (65) | |
Yes | 12 (35) | |
No | 21 (62) | |
Did not say | 1 (3) | |
Yes | 13 (38) | |
No | 19 (56) | |
Did not say | 2 (6) |
Frequency of Sinasprite mobile app use by users.
Usage data per user | Median (interquartile range) |
Self-assessment questions completed | 15.0 (5.0-41.3) |
Number of meditation sessions completed | 5.5 (2.0-13.3) |
Mindfulness paintings completed | 4.0 (1.0-12.0) |
Anxiety journal entries completed | 3.5 (1.75-8.3) |
Sinasprite activities per week | 5.7 (2.7-14.1) |
Sinasprite total activity | 34.0 (16.0-84.5) |
Total number of sessions | 6.0 (3.0-13.85) |
Average length of session (min) | 6.0 (3.8-8.5) |
The relationship between improvement in the CSE questionnaire and the GAD-7 and PHQ-8 questionnaire scores was assessed. Preliminary analysis indicated no violation in the assumption monotonicity. There was a strong positive correlation between improvement in the GAD-7 and CSE questionnaire scores (ρ=.572,
Before using the mobile app, the median user reported a PHQ-8 score of 7 (IQR=2.0-11.5, indicating mild depression) and a GAD-7 score of 5.5 (IQR=3.0-11.0, indicating mild anxiety) [
Before using the mobile app, the median user not currently receiving psychotropic medications or counseling services reported a PHQ-8 of 4.5 (IQR=1.3-10.5, indicating mild depression) and a GAD-7 score of 3.0 (IQR=2.0-9.0, indicating none or minimal anxiety) [
Changes in self-reported depression at baseline and after 6 weeks of using the Sinasprite mobile app on the Patient Health Questionnaire 8 (PHQ-8).
Changes in self-reported anxiety at baseline and after 6 weeks of using the Sinasprite mobile app on the General Anxiety Disorder 7-Item (GAD-7).
Changes in self-reported confidence in coping skills at baseline and after 6 weeks of using the Sinasprite mobile app on the Coping Self-Efficacy Scale (CSE).
To assess the effects of concomitant therapies on outcomes, the changes in the self-reported questionnaire outcomes (PHQ8, GAD-7, and CSE) were modeled using a mixed-effects repeated-measures linear regression model. The variables included main effects of time, receipt of individual or group counseling, and use of prescription medications. The GAD-7 scores were transformed using square root arithmetic. Wilk-Shapiro test and Q-Q plots indicated a normal distribution, and no further transformations were necessary. This model assessed changes before and after 6 weeks of using the mobile app. The complete results can be found in
Results from mixed-effects repeated-measures linear regression model.
Questionnaires | F statistic (degrees of freedom) | ||
Intercept | 67.1 (1.0,30.0) | <.001a | |
Time | 15.5 (1.0,30.0) | <.001a | |
Individual or group counseling | 0.1 (1.0,30.0) | .78 | |
Prescription medication use | 10.2 (1.0,31.0) | .003a | |
Intercept | 186.9 (1.0,28.0) | <.001a | |
Time | 8.4 (1.0,29.0) | .007a | |
Individual or group counseling | 1.7 (1.0,29.0) | .21 | |
Prescription medication use | 3.8 (1.0,29.0) | .06 | |
Intercept | 731.9 (1.0,30.0) | <.001a | |
Time | 17.7 (1.0,29.0) | <.001a | |
Individual or group counseling | 0.3 (1.0,28.0) | .56 | |
Prescription medication use | 7.9 (1.0,28.0) | .009a |
aSignificant at the .05 significance level.
Over 4800 areas around the United States reported a shortage of mental health providers in 2017 [
The results from this study are similar to previously published studies that detailed the positive effects of different mobile app interventions on depression severity [
Key findings from this study showed self-directed engagement of Sinasprite after 6 weeks of use was associated with statistically significant improvements in self-reported PHQ-8, GAD-7, and CSE questionnaire scores. Statistically significant improvements were seen even after controlling for concomitant prescription medication and counseling or group therapies. This study also found a strong positive correlation between improvement in the CSE and GAD-7 questionnaire scores. Unexpectedly, a statistically insignificant correlation was detected between improvement in the CSE and the PHQ-8 questionnaires.
Over the 6-week study period, the median user performed approximately 6 activities per week in the Sinasprite app. Although users were encouraged to use the mobile app to meet their needs, not all activities were tracked and assessed; thus, an underestimation of actual engagement in the mobile app may have occurred. Moreover, the beta status of the mobile app may have resulted in lower levels of user engagement; use of the mobile app may substantially increase when a fully functional version is made available to the general public. However, it is noteworthy that the degree of engagement shown from the beta version resulted in statistically significant improvements in questionnaire scores for depression and anxiety severity and coping skills. Summary data provided by the Sinasprite development team reported that 74% (25/34) of users included in the analysis continued to use the app after 6 weeks of use. This is consistent with previously reported retention rates, ranging from 10% to 70%, for internet and mobile app interventions [
Use of the Sinasprite mobile app for various features may subsequently prompt use of other features. For example, the mobile app prompted users to make a painting after completion of a meditation session to promote self-awareness from the meditation experience. Also, on completion of an anxiety journal, entry users were prompted to complete a breathing exercise although this is an untracked feature. The moderate to strong correlations detected between the trackable features suggest that users were not selectively using specific features and were likely to use multiple features that may be guided by in-game prompts. Further study is needed to assess which features are more valuable for particular populations once the mobile app is finalized and released to the public.
An underestimation of the effects of the mobile app on change in self-reported questionnaires responses may have occurred for several reasons. Users may have experienced glitches and errors in the beta version that impeded their ability to benefit from the mobile app fully. Despite this limitation, it is important to emphasize that a statistically significant change was still observed between the initial and follow-up questionnaire scores.
The CSE questionnaire measures one’s confidence in their ability to carry out coping strategies when faced with external stressors and does not have thresholds to differentiate between specific levels of coping [
These study results are subject to several limitations. The retrospective nature of this study prevented investigators from accounting for initiation and discontinuation of mental health services during the 6 weeks of the Sinasprite mobile app use and recruitment of specific populations. The study also did not have a control group for comparison. The in-development status of the Sinasprite mobile app may have limited full user engagement. The fact that the vast majority of the original sample was excluded 92.4% (416/450) because of the lack of verifiable usage 61.1% (275/450) or completion of the postuse survey scores 31.3% (141/450) is concerning and leads to greater potential for bias (eg, nonrandom, self-selection). This, however, is expected as dropout rates among internet-based studies can fluctuate between 50% and 90% [
This study found that individuals’ scores for self-reported coping skills and depression and anxiety symptoms improved without additional investment of health care resources after 6 weeks of using the Sinasprite mobile app. Although encouraging, further study is warranted to evaluate the fully functional Sinasprite mobile app among a larger and more diverse population with mental health conditions, including anxiety and depression.
Screenshots of the Sinasprite mobile application home screen and two modules.
cognitive behavioral therapy
Coping Self-Efficacy Scale
General Anxiety Disorder 7-Item
interquartile range
Patient Health Questionnaire 8
Patient Health Questionnaire 9
The authors would like to acknowledge the editorial contributions of Ms Ann Taylor, Mr Bryan Foster, Mr Sherwin Colter, and Mr Ted Tanase.
ASA’s contributions included concept and design of the study, analysis and interpretation of the data, and writing and revision of the manuscript. DRA’s contributions included concept of the study, interpretation of the data, and revision of the manuscript. SS’s and DC’s contributions included concept of the study, interpretation of the data, and revision of the manuscript. MN’s contributions included concept and design of the study, interpretation of the data, and revision of the manuscript.
Ms Swatee Surve is the founder and chief executive officer of Litesprite. There are no other conflicts of interest to report.