Journal of Mental Health

ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20

Development of a mental health smartphone app:

perspectives of mental health service users

John Goodwin, John Cummins, Laura Behan & Sinead M. O’Brien

To cite this article: John Goodwin, John Cummins, Laura Behan & Sinead M. O’Brien (2016):
Development of a mental health smartphone app: perspectives of mental health service users,
Journal of Mental Health, DOI: 10.3109/09638237.2015.1124392

To link to this article: http://dx.doi.org/10.3109/09638237.2015.1124392

Published online: 06 Jan 2016.

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ISSN: 0963-8237 (print), 1360-0567 (electronic)

J Ment Health, Early Online: 1–7

! 2015 Taylor & Francis. DOI: 10.3109/09638237.2015.1124392

Development of a mental health smartphone app: perspectives of

mental health service users
John Goodwin1,2, John Cummins3,4, Laura Behan5, and Sinead M. O’Brien6,7
1
Department of Nursing and Midwifery, University of Cork, Cork, Republic of Ireland, 2St. Michaels Unit, North Lee Mental Health Services, Cork,
Republic of Ireland, 3Department of Nursing and Midwifery, University of Cork, Cork, Republic of Ireland, 4Community Mental Health Team, North
Lee Mental Health Services, Cork, Republic of Ireland, 5Department of Allied Psychology, University of Cork, Cork, Republic of Ireland, 6Home Based
Crisis Team, North Lee Mental Health Services, Cork, Republic of Ireland, and 7Department of Psychiatry, University of Cork, Cork, Republic of Ireland

Abstract Keywords
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Background: Current mental health policy emphasises the importance of service user App, mental health, service user, smartphone,
involvement in the delivery of care. Information Technology can have an effect on quality technology
and efficiency of care.
Aims: The aim of this study is to gain the viewpoint of service users from a local mental health History
service in developing a mental health app.
Method: A qualitative descriptive approach was used. Eight volunteers aged 18–49 years were Received 16 March 2015
interviewed with the aid of a semi-structured questionnaire. Revised 13 August 2015
Results: Interviewees defined a good app by its ease of use. Common themes included Accepted 4 November 2015
availability of contact information, identifying triggers, the ability to rate mood/anxiety levels Published online 24 December 2015
on a scale, guided relaxation techniques, and the option to personalise the app. The researchers
will aim to produce an app that is easily accessible, highly personalisable and will include
functions highlighted as important (i.e. contact information, etc.).
Conclusions: This research will assist in the development of an easy-to-use app that could
increase access to services, and allow service users to take an active role in their care. In
previous studies, apps were developed without the involvement of service users. This study
recognises the important role of service users in this area.

Introduction studies (Ben-Zeev et al., 2013; Ennis et al., 2014). The use of
technology within mental health care has taken many forms
Current mental health policy notes the importance of
over the last number of years. Internet-based treatments (such
partnership between mental health professionals and service
as computerised cognitive behavioural therapy) can often
users (Department of Health & Children, 2006; Office of the
prove cheaper than traditional treatments, whereas also
Nursing and Midwifery Services Director, 2012); however,
reducing waiting lists and allowing service users access to
the literature highlights certain key areas where partnership
treatment at times that are suitable to them (Cuijpers & Riper,
does not occur. The Mental Health Commission (MHC, 2011)
2014). Service users have found email assistance for emotional
found 36.8% of service users in acute wards did not feel that
first aid to be helpful (Gilat & Reshefb, 2014), and some
mental health practitioners encouraged them to voice their
service users even report preferring this system to traditional
opinions of the services they received. Goodwin & Hapbell
face-to-face therapy (Hadjistavropoulos et al., 2014).
(2006) found that service users from different mental health
Videoconferencing technology can save both time and cost,
services were not treated as active participants in their care,
whereas also allowing for wider dissemination of clinical
and that mental health practitioners were unwilling to involve
expertise (Pesamaa et al., 2004; Pignatiello et al., 2010). Text
them in decisions relating to treatment. Service users in the
messaging as an adjunct to psychotherapy is regarded as a
community have also reported a lack of a partnership
feasible means of communication by service users (Aguilera &
approach being evident (Cunningham & Slevin, 2005;
Muñoz, 2011). Use of text messaging can also improve
Dogra et al., 2008).
attendance at out-patient clinics (Bauer et al., 2012). In terms
One method of strengthening this partnership is to include
of documentation, those with experience in the use of
service users in the development of technologies relevant to
electronic record-keeping have noted that it increases acces-
their care; such an approach has proved successful in previous
sibility to patient information, and is often easier to read than
traditional pen-and-paper documentation (Baillie et al., 2012).
Correspondence: John Goodwin, MA, PG Dip (PIMHC), BA (Hons), Health information technology can improve performance
BSc (Hons), ALCM, RPN, C/O St. Michaels Unit, Mercy University
Hospital, Grenville Place, Cork, Republic of Ireland. E-mail: and communication, leading to efficient and safe care
john.goodwin@hse.ie (Institute of Medicine, 2012). Patient health technology
 2 J. Goodwin et al.
systems will become a very necessary part of any high quality
service provider (Chaudhry et al., 2006; Fetter 2009).
Although many support systems require a large amount of
investment and training (such as patient care information
systems), there is a cheaper and potentially very useful type of
tool being used at present in the area of mental health known
as smartphone applications (apps). The use of apps has grown
exponentially, with global sales of smartphones rising by 40%
(one billion units) in 2013; it is estimated that 1.89 billion
units will ship in 2018 (CSS Insight, 2014).
Service users have been included at different levels in the
development of both physical and mental healthcare-related
apps. Service users’ perspectives have been examined in
relation to existing apps for physical health, with the aim of
informing future development of similar apps. Dennison et al.
(2013) note how characteristics such as accuracy of data-
tracking have been identified by smartphone users as
important in supporting physical health-related behaviour
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changes. Service users have played a role in the evaluation of
apps in their early stages of development. People experiencing
physical health issues were interviewed in developing an app
specific to their purpose (headaches) (Huguet et al., 2014).
The authors found that it was necessary to include these
individuals during the design process. A similar approach was
adopted by Musseig et al. (2013) in terms of sex education,
where the importance of user-friendly content was empha-
sised by participants. A sample of adolescents suffering with
chronic pain were interviewed by Stinson et al. (2014); the
content of the proposed pain-related app will be based around
the four major themes which emerged from these interviews.
Cafazzo et al. (2012) included service users at different stages
in the development of an app for the self-management of type-
1 diabetes. The app is based around the needs of these
individuals, and service users were also called upon to
validate the app.
With regard to mental health, service users also have an
important role to play in the validation of apps. Ly et al. (2012)
measured how participants experienced an acceptance and
commitment therapy-based smartphone app. They found that
service users reported a generally positive experience in
relation to the use of this app, thus validating its use within this
area. Ben-Zeev et al. (2013) also encouraged service user
validation of a mental health-based app, with a particular
emphasis on functionality, in order to create a user-friendly
interface. Participants interviewed by Dennison et al. (2013)
commented on existing apps, stating that an important
characteristic of mental health apps was the speed at which
they can improve one’s mood. Service users have also been
directly involved in the development of healthcare apps.
Mental health service users (specifically those with a diagnosis
of schizophrenia) were surveyed by Ben-Zeev et al. (2013).
Although a large sample of service users (n ¼ 903) was initially
interviewed to determine smartphone use behaviours, the
content of the app was predominantly practitioner-decided.
From the extant literature, it is clear that service users are
often included in studies in order to evaluate existing apps.
Though it is evident that service users have a role in the early
stages of physical health app development, they are less often
included at this stage in the development of mental
health apps.
J Ment Health, Early Online: 1–7
Aims
Considering it is of current importance within current mental
health policy to involve service users in all levels of service
delivery, it is the aim of this project to determine if service
users are interested in a North Lee Mental Health Services
(NLMHS) app, and to include these participants in developing
an app that will meet their specific needs.
Methods
A qualitative descriptive design was used. Ethical approval
was sought and granted from the Clinical Research Ethics
Committee of the Cork Teaching Hospitals.
Sample
Service users from the NLMHS were approached for partici-
pation in this study. This is a mental health service based in
the south of Ireland, which caters for a population of 181 802
people (Central Statistics Office, 2012). From January to
December 2012, 26 647 attendances were recorded by the
various day hospitals, day centres and out-patient clinics
within the North Lee sector (J. Shone, personal communica-
tion, 25 July 2013).
Service users aged 18–49 years, who used both smart-
phones and apps, were included in the study. According to
Eircom (2013), between 54% and 77% of people within this
demographic own a smartphone, compared with only 27% and
10% in the age groups of 50–64 years and 65 years,
respectively.
Volunteer sampling of NLMHS service users was used.
Service users were approached in the NLMHS day hospitals
and out-patient clinics. Ten service users initially agreed to
partake in the study. Two service users dropped out of the
study, resulting in a final number of eight participants. Within
qualitative research, there is no official agreement on the
minimum sample size. However, a small sample can have
sufficient depth, providing data saturation is reached
(Bryman, 2012; Charmaz, 2012; Parahoo, 2014). The final
sample comprised three males and five females, with a mean
age of 36.9 years. The diagnoses of these participants were as
follows: depression (n ¼ 2), schizophrenia (n ¼ 2), bi-polar
affective disorder (n ¼ 3) and anxiety disorder (n ¼ 1). All
participants owned either a Samsung Galaxy or an iPhone,
and regularly used apps.
Data collection
Semi-structured interviews were held with each participant.
In order to inform the interview schedule, existing mental
health apps were examined. The app stores of the four main
smartphone operating systems were searched (iPhone,
Windows, Android and Blackberry) for mental-health apps.
Due to its relevance to the topic, the authors also accessed
apps via the Zur Institute (2013), a continuing education
resource for psychotherapists, which offers a certificate in
mental health apps and how these can be used in partnership
with service users. Apps that were not aimed at service users
were excluded. Several apps did not include information
explaining the functions of the app and others did not include
information pertaining to the interface. The apps examined
 DOI: 10.3109/09638237.2015.1124392
are listed in Table 1. The various functions and features of
apps were incorporated into the interview schedule.
Interviews were conducted in three different day centres
operating within NLMHS (depending on proximity to the
participant). These were conducted simultaneously by J.G.
and J.C., audio-recorded and transcribed. The participants
were made aware of the purpose of the study beforehand, and
informed that data collected would assist in the construction
of an app. A pilot interview was conducted, and prompts
were modified after this interview; data from the pilot
interview were included in the overall study. Interviews lasted
between 40 and 65 min. Data saturation was reached after the
eighth interview, when no new information or themes
emerged.
Data analysis
Thematic analysis was completed by one co-author (L.B.); the
data were coded using NVivo version 10 (QSR International
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Pty Ltd., 2012). Transcripts were coded sentence-by-sentence.
Focused coding followed, in which data segments judged to
be similar were grouped into individual categories. Themes
and sub-themes were developed from these focused codes.
In order to maintain rigor, the consolidated criteria for
reporting qualitative research checklist, where the methodo-
logical process is reported in a detailed fashion, was used
throughout the study (Tong et al., 2007). Notes were
maintained at all times to track decisions and help to verify
the link between the original data and the findings. Though
participants did not review the data, two external auditors
validated the data analysis process and helped to minimise
bias by reading the original transcripts and confirming the
integrity of the identified themes.
Results
The main type of apps used by participants can be categorised
into information seeking, entertainment, organisational, social
networking and media. Only three participants reported using
apps for therapeutic purposes, such as diary keeping, daily
meditation and mindfulness practices. All eight participants
expressed interest in using a NLMHS app.
A good app was defined by 6 out of 8 participants by its
ease of use. Participants discussed the importance of apps
being accessible, self-explanatory and simply laid out.
‘‘[T]hey have to be kind of self-explanatory.’’ [Patient
(P) 6]
‘‘You can see it, the way it’s laid out and the way
it’s colour-organised and stuff like that, it’s easy to
remember things, and really laid out in an easy way to
remember it.’’ (P7)
‘‘They need to be accessible, they need to have what
you’ve been told they have. It needs to be simple and easy to
use, so fairly straightforward.’’ (P2)
A personal element to the app, according to the needs of
the service user, was viewed as a potential therapeutic benefit
by four participants. Suggestions for this personalised app
included:
(a) Regular customised questions.
‘‘For everyone it would be customised, but like for me,
when I’m well to make a list for myself would be great and for
Mental health smartphone app 3
my phone to remind me every day, or ask me, you know even
five questions every day, just to see if I’m still on track.’’ (P4)
(b) For the app to provide a storage setting that service
users could update with positive pictures and quotes, which
could be accessed in times of stress.
‘‘[L]ike your bad thought process and stuff and things like
that, you know they could be put into an app, and it would be
good to remind yourself of them. Like there are ones for like
when you lose your temper and there’s just small sen-
tences and things to help you through it like when it does
happen.’’ (P7)
‘‘So maybe if it keeps generating things and it sends me a
nice picture of where I could look in case I’m indoors
or . . . it’s just stars or sun, which is kind of calm, or it may be
it literally suggests me to sit down.’’ (P1)
Daily reminders were an overriding theme and introduced
independently by 7 of the 8 participants. One way in which
reminders were seen as beneficial was in an organisational
capacity; this was cited by four participants. Participants
suggested reminders to attend scheduled appointments, to
take medication or to complete daily therapies.
‘‘A reminder for meds: absolutely vital, because I have
more than once taken [. . .] my antipsychotic in the evening
and then gone and taken it again in the morning.’’ (P2)
‘‘Yeah maybe if there was an app telling me you have to do
your homework, you have to don’t get stressed . . . maybe a
constant reminder.’’ (P1)
‘[F]or dates and stuff like that and to keep a good schedule,
keep a schedule.’’ (P3)
‘‘I’d forgotten one [appointment] like . . . you can very
easily . . . it’s free, like you can set up text alerts and stuff like
that for the day before, using online services.’’ (P6)
Using reminders for therapeutic purposes was discussed by
four participants. This included regular and sporadic daily
reminders showing customised pictures, messages and lists.
Regular messages linked to updated articles or techniques
were also deemed important.
‘‘Maybe that could go with the reminders you know . . . if
it’s being asked what, what things do keep people calm, then
you have a list already there immediately.’’ (P1)
‘‘[T]here are ones for when you lose your temper and
there’s just small sentences and things to help you through
it . . . when it does happen, they could be in the app, you know,
and you could just open the app and remind yourself of those
things.’’ (P7)
Interviewer-suggested apps included a contact information
app, relaxation techniques, mood/anxiety rating apps and
diary apps, e.g. sleep, exercise and diet. The majority of
participants said they would be interested in using all of these
apps. All eight participants felt a contact information app
would be helpful with additional suggestions including
information on classes available, location of centres and
information on relevant organisations/charities. Trigger dia-
ries and mood/anxiety rating scales were seen as extremely
helpful. One of the perceived major benefits of these was the
ability to keep a diary/log to help monitor their mood over a
period of time. Participants were also interested in using
relaxation/breathing techniques in the form of an app,
especially if this could be combined with music.
Participants suggested that the app could use responses they
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4

Table 1. Apps which informed interview schedule.

Name of app Reference Genre Aim of app Population aimed at

Shine Mental Ill health (Shine, 2013) Education based Promotes awareness of mental ill-health, as well as Users experiencing psychosis, schizophrenia,
providing information on resources for service depression and bipolar affective disorder.
J. Goodwin et al.

Depression Test & Tracker (Sonesso, 2010)
CBT Referee (CBT Referee, 2010)
The Linden Method Program (The Linden Method, 2010)
Sad Scale (Deep Pocket Series, 2013)
T2 Mood Tracker (National Centre for Telehealth &
Technology 2012)
Live Happy (Signal Patterns, 2008)
Optimism Apps (Optimism Apps, 2010)
eCBT Mood (Mind Apps, 2010b)
eCBT Calm (Mind Apps, 2010a)
eCBT Trauma (Mind Apps, 2010c)
Stress Check (Azumio Inc., 2013)
Mental Health ‘Wats’ (Soltan, 2012)
users
Diary/rating scale Mood can be monitored by the user on a weekly Users experiencing depression
basis, and it is suggested that this information is
presented to the user’s doctor.
Diary Diary system where users key in their thoughts, with Users experiencing negative thought patterns
the aim of tracking negative thought patterns and
learning from this process
Education and These apps include relaxation audio files and Users with post-traumatic stress disorder
activity based instructions on deep-breathing techniques. There (PTSD), agoraphobia, anxiety, and obses-
is also an information component to educate users sive compulsive disorder.
in relation to their specific mental health issue.
Diary/rating scales Based around depression rating scales to monitor A general depression scale, a scale for
mood. Information can be stored and presented as children and older adults, and a post
a graph over time. partum scale are included.
Diary/rating scale Users can self-monitor their emotional experiences Users experiencing stress, anxiety, depression
over a period of time. and PTSD.
Activity based Guides users through a set of activities proven to Not specific to any particular mood disorder
boost mood, which are based around social used with a wide range of mental health
relationships, diet and exercise. issues.
Diary/rating scales Self-monitoring apps providing ratings scales. For a wide-range of mental health issues.
Mood, exercise, sleep, staying well strategies, and
triggers diaries are included.
Diary/rating scales Users key in automatic thoughts from a drop-down Users experiencing depression.
list, with the aim of challenging these thoughts.
Rating scales are also used to highlight how true
users believe their automatic thoughts to be.
Diary/rating scales Rating scales are used to map a user’s stress over Users experiencing stress.
time. Psychoeducation in relation to relaxation
skills is included.
Education and Diary/ Users key in automatic thoughts from a drop-down Users who have experienced a traumatic
rating scales list, with the aim of challenging these thoughts. event.
Rating scales are also used to highlight how true
users believe their feelings and thoughts to be.
Information on PTSD is also included here.
Physical monitoring Uses heart-rate monitoring technology to detect a Users experiencing stress/anxiety.
user’s pulse, and then quantifies the effects of
stress on their bodies. Also includes advice on
using deep-breathing techniques.
Education This app includes information on different mental For a wide-range of mental health issues.
health issues, and contact information for relevant
mental health issues.
J Ment Health, Early Online: 1–7
 DOI: 10.3109/09638237.2015.1124392 Mental health smartphone app 5
Table 2. Feedback on interviewer-suggested apps.

Suggested app
Contact information
Trigger identification
Sleep/food/exercise diaries
Mood/anxiety ratings
Relaxation/breathing techniques
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Number of
participants
interested
in app Additional suggestions by participants
Eight  Contact information for the Home Based Crisis Team (P2)
 Addresses/maps to centres, classes and meeting (P3, P5, P8)
 Option to add own key worker contacts also, i.e. personalised (P2, P3)
Seven  Dropdown menu of key triggers typed in initially (P6)
 Make trigger diary into a game to play when stressed (P3)
 Writing triggers as diary entries to look back on (P4, P5, P8)
Seven  Link all diaries together in one app (P4, P8)
Seven  Out of a scale from 1 to 10 (P2)
 Shown as a graph to monitor or log mood and anxiety over time (P7, P5, P8)
 Linked with diaries (P7, P5, P2)
 If mood is low or anxiety is high, personalised suggestions are introduced (P5)
Seven  Add a warning about the long silences common to meditation pauses (P2)
 Also include relaxing/atmospheric music without talking (P3)
 Audio app providing advice for illiterate patients (P3)
 Opportunity to rate these relaxation/meditation exercises so that one would know which ones
help the best. (P5)

input over a period of time to form a graph. Such graphs
would be beneficial when meeting with their consultant, and
could be used to simply and quickly describe their progress
over a period.
The possibility to connect and link together all these
functions together to provide a wide and varied app was
widely sought.
Discussion
The aim of this study was to ascertain if there was interest
from participants in the development of a NLMHS app, and to
determine what content service users would wish to include in
such an app. Overall, there was interest in the development of
a NLMHS app. Although only three participants had used
therapeutic apps in the past, every participant was interested
in using a NLMHS app, were it to become available.
Inclusion of contact information for the various centres
within NLMHS was highlighted by every participant as
important, and so this will be available in the app, on a
separate tab/page. There will be an option to personalise this
information, adding details such as key worker names and
contact numbers. The option to customise/personalise apps
emerged as a significant theme, and is similar to findings
from other authors (Dennison et al., 2013; Jaehee et al., 2014;
Price et al., 2014); using contact information in this fashion
has also been cited as important to participants (Fox, 2014;
Shine, 2013; Soltan, 2012; Travis & Tay, 2011).
Reminders have been recomended by several authors (Ben-
Zeev et al., 2013; Dennison et al., 2013; Musseig et al., 2013).
This was another popular area for participants, and something
most (n ¼ 7) felt would be useful in a NLMHS app. Again,
this was an area in which the option to personalise the app was
viewed as beneficial. Both regular reminders and diaries were
seen by participants as an opportunity to reflect, thus
indicating that these functions may be used in conjuction
with each other. A basic template diary could be used to keep
track of the specific needs of the service users (i.e. diet, sleep,
triggers). The diary would be combined with a basic template
rating scale, used to rate whatever the service user chooses,
and would form a graph over time. Other authors (Dennison
et al., 2013; Huguet et al., 2014; Rosen, 2012; Sonesso, 2010)
have also noted participants’ interest in using apps in this
fashion. Such a function could be used to monitor service
users’ recovery on an individual basis, but could also provide
invaluable feedback for their care team and key workers
(Deep Pocket Series, 2013; Dulin et al., 2013; National Centre
for Telehealth & Technology, 2012; Optimism Apps, 2010;
Tate et al., 2013). When certain keywords are entered, or
certain values are inputted on the rating scale, pre-configured
reminders/strategies that have been successful for the service
user in the past would signal them and assist them in their
recovery journey.
This study had some limitations. The emergent themes
were reliant on information provided by particpants; however,
there can be a gap between what participants say and what
they actually do (Ziebland & McPherson, 2006). Volunteer
sampling was used, often cited as a weak sampling method
(Parahoo, 2014). It must also be acknowledged that a small
sample size was used.
Conclusion and implications for practice
Participants expressed an interest in combining interviewer-
suggested apps along with technologies with which they were
previously familiar. However, considering the emphasis
participants also put on a successful app being uncomplicated,
it would be impractical to attempt to synthesise all of these
ideas into a single app. Instead, it is the researchers’ intention
to devise a simpler app that would reflect the areas most
saliently identified by the participants. The researchers aim
for this app to be easily accessible, straight-forward and
visually appealing, as identified by participants and the
overview of relevant apps presented in Table 2. Relaxation/
breathing techniques would involve further expense in
devising and developing, would put a strain on data storage
limitations, would be difficult to personalise sufficiently and
already exist as fully functioning apps. Considering these
limitations, a relaxation/breathing technique funtion will not
be incorporated into the NLMHS app.
 6 J. Goodwin et al.
This research will assist in the development of an attractive
and simple-to-use app that can be personalised by individuals
to suit their specific needs. It would include both contact
information for NLMHS, and a diary/reminder function to be
used by the individual on a daily basis and as a tool to use
with their care team/key worker. Evaluation of the app will
also include service users, similar to previous research (Ben-
Zeev et al., 2013; Ennis et al., 2014). Involving service users
in developing apps emphasises the partnership approach
important to the mental health services. This allows service
users to take an active role in their care, to voice concerns
about how care is delivered and to actively impact upon
service delivery. Traditionally, the realm of developing
healthcare apps has been practitioner led; this research has
demonstrated how service users can provide insights into app
development, using their own experiences to assist practi-
tioners in determining the way in which mental health care
should evolve.
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Acknowledgements
The authors wish to acknowledge Mr. Ned Kelly and
Mr. James O’Mahony, North Lee Mental Health Services,
for their assistance in developing this article. The authors also
acknowledge the contributions of Dr. Karen McCarthy and
Mr. Declan McCarthy in the interpretation of the findings
presented in this article.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the article.
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