At the Intersection of Health, Health Care and Policy

Cite this article as:

Sarah P. Jones, Vikram Patel, Shekhar Saxena, Naomi Radcliffe, Salih Ali Al-Marri
and Ara Darzi
How Google's 'Ten Things We Know To Be True' Could Guide The Development Of
Mental Health Mobile Apps
Health Affairs, 33, no.9 (2014):1603-1611

doi: 10.1377/hlthaff.2014.0380

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 Mental Health

By Sarah P. Jones, Vikram Patel, Shekhar Saxena, Naomi Radcliffe, Salih Ali Al-Marri, and Ara Darzi
doi: 10.1377/hlthaff.2014.0380

How Google’s ‘Ten Things We

HEALTH AFFAIRS 33,
NO. 9 (2014): 1603–1611
©2014 Project HOPE—
The People-to-People Health

Know To Be True’ Could Guide Foundation, Inc.

The Development Of Mental

Health Mobile Apps
Sarah P. Jones (s.jones12@
ABSTRACT From 2011 to 2030, mental health conditions are projected to imperial.ac.uk) is a fellow of
the World Innovation Summit
cost the global economy $16 trillion through lost labor and capital for Health (WISH), Qatar
output. The gold standard of psychological interventions, one-on-one Foundation, and a research
associate in mental health
therapy, is too costly and too labor-intensive to keep up with the technologies at the Centre for
projected growth in demand for mental health services. Therefore, new Health Policy, Institute of
Global Health Innovation,
solutions are needed to improve the efficiency of mental health care Imperial College London, in
delivery and to increase patient self-care. Because 85 percent of the the United Kingdom.

world’s population has wireless signal coverage, there is an Vikram Patel is cochair of the
unprecedented opportunity for mobile technologies to incorporate Mental Health Forum at WISH
and a professor of
psychological self-care into people’s daily lives and relieve workforce international mental health
shortages. In this article, we suggest that policy makers look to and a Wellcome Trust Senior
Fellow in clinical science at
technology innovators for guidance. For example, Google’s principles, the Centre for Global Mental
called “Ten Things We Know To Be True,” are useful for understanding Health, London School of
Hygiene and Tropical
the drivers of success in mobile technologies. For principles such as Medicine, in the United
“focus on the user and all else will follow,” we identify examples of how Kingdom.

evidence-based mobile mental health technologies could increase patient Shekhar Saxena is cochair of
self-care and reduce the demand for one-on-one psychological the Mental Health Forum at
WISH and director of the
intervention. Department of Mental Health
and Substance Abuse, World
Health Organization, in
Geneva, Switzerland.

Naomi Radcliffe is the forum

T
he World Economic Forum esti-
mates that from 2011 to 2030, men-
tal health conditions will cost
the global economy $16 trillion
through lost labor and capital out-
put.1 The average annual mental health burden
for each of those twenty years will be equivalent
to 1 percent of the 2012 global GDP.2 In compari-
son, four other noncommunicable diseases com-
bined—cardiovascular disease, chronic respira-
tory disease, cancer, and diabetes—will cost the
global economy $30 trillion from 2011 to 2030.1
Finding, diagnosing, and treating more people
with mental health conditions could reduce the
burden of mental illness.3 Richard Layard and
David Clark argue that “it would cost nothing
(in net terms)”4(p4) to treat people with depres-
sion and anxiety. Their calculations are based on
UK data on the economic gain from a 4 percent fellow of the Mental Health
increase in employment after treatment for de- Forum at WISH and a policy
fellow in patient safety at the
pression and anxiety, which results in reduced Centre for Health Policy,
benefit payments and higher tax receipts.4 Evi- Institute of Global Health
dence from high-income countries illustrates Innovation, Imperial College
London.
that increased employment and tax revenue,
combined with decreased social welfare costs,
Salih Ali Al-Marri is assistant
could outweigh economic outlays for treating secretary general for medical
the most common mental health problems.5 affairs in the Supreme Council
It is unlikely that there will ever be enough of Health, in Doha, Qatar.
highly trained professionals to treat all patients
Ara Darzi is executive chair of
globally with the therapeutic “gold standard” of WISH, Qatar Foundation, and
one-to-one therapy. Data on mental health work- director of the Institute of
force shortages6 highlight very large human re- Global Health Innovation,
Imperial College London.
source shortfalls, especially in low- and middle-
income countries.7 In low-income countries,
projections for the period 2011–30 suggest a fu-
ture economic burden of $8.3 billion per country

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Mental Health

as a result of mental illness, but there is only one
mental health worker for every 100,000 people
to address this problem. In lower-middle-income
countries, where the projected economic burden
is $40 billion per country during the same time
period, there are only ten mental health workers
per 100,000 people (Exhibit 1).
With such a large anticipated burden, govern-
ments cannot afford not to address mental
health conditions. However, governments are
not spending enough to tackle this future bur-
den: Median government spending on mental
health around the world was only $US1.63 per
capita in 2011.8 Labor costs are estimated to ac-
count for approximately two-thirds of total
health expenditures across health care interna-
tionally,9 and mental health services depend pri-
marily on a human workforce to deliver care.7
Efficiency improvements and increased pa-
tient self-care are potential ways to help make
up for the labor shortfall. The World Health Or-
ganization (WHO) has highlighted the low level
of workforce efficiency as a major shortcoming
to be addressed in mental health care, alongside
scarcity and inequality in access to services.7
Creating efficiencies in mental health labor is
particularly challenging because it relies more
on communication between people and less on
the equipment and tools used for many other
health services. Evidence indicates that task
sharing by having more highly trained workers
supervise care delivery by workers who are less
highly trained and less expensive can increase
access to care and free up highly trained workers’
time.10 However, task sharing still relies on
human capital input, which is the most costly
solution.
Pharmaceutical therapies can offer labor effi-
ciencies by reducing face-to-face therapy time.
However, a meta-analysis of evidence from the
United States and the United Kingdom suggests
that patients with the most common mental dis-
orders, such as major depressive disorders, may
prefer psychological therapy to medication.11
Helping patients become better at self-care could
create additional efficiencies by freeing up men-
tal health workers’ time.
Mobile technologies are still largely untapped
sources of innovation to improve efficiency and
patient self-care in mental health. Mobile

Exhibit 1

Projected Average Economic Burden Of Mental Illness Per Country And Median Number Of Mental Health Care Workers Per
100,000 Population, 2011–30

SOURCE Authors’ analysis of data from the following sources: (1) Bloom DE, et al. The global economic burden of non-communicable
diseases (Note 1 in text). (2) World Bank. Country and lending groups [Internet]. Washington (DC): World Bank; c2014 [cited 2014 Jul 30].
Available from: http://data.worldbank.org/about/country-classifications/country-and-lending-groups#High_income. (3) World Health
Organization. Mental health atlas 2011 (Note 7 in text). Graph 4.2.2. NOTES Economic burden is reported in billions of 2010 US dollars.
This is depicted by blue bars and relates to the left-hand y axis. The average burden, as per Bloom and colleagues’ EPIC1 Model based
on the lost output method, was calculated by dividing the projected economic burden data per income group by the total number of
countries per World Bank Income Group as of April 4, 2014. Figures for mental health care workers were based on responses from 79 of
181 possible World Bank member countries for psychiatrists, other medical doctors, nurses, psychologists, social workers, occupa-
tional therapists, and other health care workers (such as community health workers, nursing associates, and auxiliaries) in mental
health facilities. This is depicted by the red line and relates to the right-hand y axis. Rates per 100,000 population were calculated
using United Nations Department of Economic and Social Affairs. World population prospects: the 2012 revision [Internet]. New York
(NY): UN; [cited 2014 Jul 30]. Available from: http://esa.un.org/unpd/wpp/unpp/panel_population.htm.

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phones have widespread consumer appeal, and
wireless signal coverage is in place for 85 percent
of the world’s population.12 The portability, pri-
vacy, and round-the-clock availability of mobile
phones offer mental health workers and patients
a direct, private, and instantaneous method of
communication as well as access to information
and self-care support almost anywhere in the
world.
The International Telecommunication Union
reports a world aggregate of 85,473 mobile
phone subscribers per 100,000 people (Exhib-
it 2). In contrast, there is a world median of only
10.3 mental health care workers per 100,000
people. Thus, the ratio of phone subscribers to
mental health care workers is more than 8,000 to
1. In low-income countries, this ratio increases to
more than 30,000 to 1. To take advantage of a
communication opportunity of this magnitude,
the mental health care workforce requires inno-
vations to support greater access to psychologi-
cal therapies.
Psychological therapies are primarily talk-
based interventions (based on communication
and behavior change) and may be well suited to
mobile environments. Commercial applications
(apps) provide patient self-care homework and
thought diaries that are used outside clinical
sessions in cognitive behavioral therapy.
Studies of mobile mental health apps indicate
that mobile mental health innovations have the
potential to increase efficiency by supporting
clinicians’ functions, including training and ad-
ministration.13–16 These innovations include mo-
bile apps that encourage adherence to treatment,
such as text-based appointment reminders and
automated text messages following discharge
from an inpatient treatment facility.
In this article we offer a perspective on how to
adopt mobile technologies to help close the men-
tal health treatment gap. We suggest that in ad-
dition to the standard trial outcome measures of
efficacy and cost-effectiveness, policy makers
should consider a series of principles developed
by Google that are related to mobile technology,
such as the need to make user experience a top
priority. We identify examples of evidence-based
mobile mental health technologies that embody
one or more of these principles. We place these
examples in the context of increasing patient
self-care without sacrificing quality.
We encourage health policy makers and men-

Exhibit 2

Ratio Of Mobile Phone Subscriptions To Mental Health Care Workers Per 100,000 Population, By World Income Group

SOURCE Authors’ analysis. NOTES The analysis of mobile phone subscriptions and mental health care workers per 100,000 population
results in a ratio between the two, with data on the number of mental health workers in the denominator (the ratio is depicted by the
red line and does not relate to either y axis). The number of mobile phone subscriptions is depicted by blue bars and relates to the left-
hand y axis. Mobile phone subscriptions are subscriptions to a public mobile phone service that uses cellular technology. The sub-
scriptions provide access to the public telephone network. Postpaid and prepaid subscriptions are included. Mobile cellular subscrip-
tion figures were extrapolated from a group aggregate per 100 population to a per 100,000 population by multiplying by 1,000 base
figures from International Telecommunication Union, World Telecommunication/ICT Development Report and database, and World
Bank estimates [Internet]. Washington (DC): World Bank; [cited 2014 Jul 30]. Available for download from: http://data.worldbank
.org/indicator/IT.CEL.SETS.P2?order=wbapi_data_value_2012+wbapi_data_value+wbapi_data_value-last&sort=asc. The sources of the
figures for mental health workers and rates per 100,000 population are given in the notes to Exhibit 1. The number of mental health
workers is depicted by green bars and relates to the right-hand y axis.

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Mental Health
tal health care providers to consider stepping
outside their comfort zones to think more like
technologists when developing strategies for the
future of mental health care. This has become
especially critical since 2013, when the World
Health Assembly, representing the world’s polit-
ical health leadership, passed the first Mental
Health Action Plan. The plan includes clear tar-
gets for countries to achieve by 2020.17
Mobile Technologies In Evidence-
Based Mental Health Services
The rapid adoption of mobile phones and their
wide appeal for people at all income levels18 has
triggered a profound evolution in person-to-per-
son communication. Mobile phone subscrip-
tions in low-income countries—where Internet
penetration is more likely to be low, compared to
high-income countries19—grew from under 1 mil-
lion in 2002 to over 40 million in 2011, a growth
rate of over 4,100 percent (for details about mo-
bile phone penetration in low-income countries,
see online Appendix 1).20
Applications of mobile technology to areas of
general health care span almost every aspect of
service and delivery. Mobile health (mHealth)
technologies can extend geographic access to
services by replacing or supplementing a tradi-
tional office visit, facilitating patient communi-
cation with providers, improving data manage-
ment, streamlining financial transactions, and
mitigating fraud and abuse. The WHO proposed
a useful taxonomy of e-health information and
communication technologies across domains of
training, service delivery, and clinical practice21
(for an overview of the key functional opportu-
nities for mobile technology in mental health,
see Appendix 2).20
Specific mobile technology implementations
include public awareness campaigns, workforce
training, appointment reminders, record keep-
ing, symptom monitoring, self-management,
clinical tools such as decision making, and clini-
cian-supported and self-guided interventions.
Mobile health interventions applied to high-
burden, chronic conditions such as diabetes
have already produced some cost savings and
other benefits. For example, mobile self-manage-
ment with clinician support through automated
text messages at the University of Chicago re-
sulted in improved glycemic control and net cost
savings between May 2012 and February 2013.13
Reviews and meta-analyses of a broad range of
mHealth applications across many areas of phys-
ical illness have revealed modest benefits from
mHealth interventions, including improved ac-
cess to services and outcomes such as increased
attendance at appointments.22,23
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Mobile health
interventions applied
to high-burden,
chronic conditions
such as diabetes have
already produced
some cost savings and
other benefits.
In low- and middle-income countries, mental
health programs were the third most commonly
reported mHealth programs in a recent WHO
survey.21 Hundreds of untested mobile mental
health apps are commercially available online.
Evidence for the effectiveness of mental health
apps is accumulating rapidly.24,25 However, most
trials have small sample sizes and pre-post de-
signs with no control groups. In addition, most
have been conducted primarily in high-income
countries and lack cost-effectiveness data or sub-
stantial follow-up periods. Large randomized
controlled trials of mental health apps have yet
to be concluded.
The future of mobile mental health could in-
clude programs that use standard question-
naires to facilitate the collection and analysis
of patient-generated information, such as data
related to screening or monitoring of symptoms.
It could include discrete components of interven-
tions, full interventions, or adherence support,
such as appointment reminders delivered via
text. Apps could incorporate data from mobile
phones and wearable devices to identify loca-
tions where stressful episodes occur and when
increased heart rate and galvanic skin responses
are detected.
Although the evidence in favor of mobile apps
for mental health care is mounting,14,26 the digi-
tal divide is a substantial concern. The divide is
likely to decrease with the proliferation of cheap
smartphones and mobile broadband penetra-
tion. Nonetheless, it could temporarily increase
health inequalities between those who have ac-
cess to the Internet or mobile communication
and those who do not.13
Mobile technologies have the potential to pro-
vide discreet access to mental health services in
cultures where services are limited or mental

Mobile apps have the
advantage of existing
on a device that’s
already in patients’
hands at almost any
time of day.
health problems are highly stigmatized. Mobile
apps may help circumvent the problems of low
Internet penetration in low- and middle-income
countries because they do not require the use of
web pages.
Barriers to the adoption of mobile technolo-
gies by mental health practitioners are likely to
include the lack of evidence-based commercially
available technology, the lack of clarity about
clinician reimbursement and insurance for the
products that do exist, and unknown clinician
attitudes about mobile mental health tech-
nologies.
The Labor Supply Problem: What
Would Google Do?
The development of effective and universally ac-
cepted mobile products and services for mental
health requires expertise about both mobile
technology and mental health on the part of
health practitioners as well as consumers.
Cross-disciplinary and cross-industry knowl-
edge and partnerships take time to develop, es-
pecially when neither cost-effectiveness nor
commercial opportunity is clear.
In addition to traditional clinical trial out-
comes, health service innovators must master
what underpins mobile technological success
to develop solutions that will create labor effi-
ciencies and encourage self-care. To gain clarity
about how to achieve this, we adapted one of the
key innovation questions asked by Peter
Drucker, the business and innovation expert:27
What does mental health innovation need to look
like to take advantage of the mobile opportunity?
Moreover, how can policy makers foster a new
breed of mobile mental health innovators?
Google publishes principles called “Ten
Things We Know to Be True” on its website.28
The principles are useful for understanding
the drivers of success in mobile technologies.
Here we apply them to the question of how the
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development of mobile mental health tools
might proceed, citing examples of existing mo-
bile apps.
The Innovation Principle: ‘It’s Best To Do
One Thing Really, Really Well’ Mobile tech-
nologists may agree with Drucker that “an inno-
vation, to be effective, has to be simple and it has
to be focused. It should do only one thing.”27(p135)
In mental health innovation, this equates to
the importance of innovations’ focusing on a
single part of the communications and care path-
ways that constitute interactions between the
patient and the provider. Innovation theory sug-
gests that innovations are more likely to be taken
up if they are specific, instead of attempting to
replace many processes at once.27 Behavior the-
ory suggests that people adopt innovations be-
cause of such factors as their perceived relative
advantage, compatibility, complexity, and abili-
ty to be tried, and because of people’s frequency
of exposure to the innovations.29 According to a
WHO survey of its member states, a popular
mHealth initiative in high-income countries
was the use of text messages to remind patients
of appointments.12
An example of a mobile innovation that fo-
cused on only one aspect of service was found
in a trial of fifty-four patients in the United King-
dom who were diagnosed with depression and
comorbid alcohol use disorder. After a month-
long inpatient stay, patients were discharged
and randomly assigned to receive either support-
ive text messages (for example, “Monitor
changes in your mood; develop a list of personal
warning signs”) two times a day or a “thank you”
text message at two-week intervals.15 At the end
of the three-month intervention, the group that
received supportive text messages had signifi-
cantly lower depression scores, consumed about
one-sixth the number of drinks per drinking day,
and relapsed for fewer total days, compared to
the group that received the “thank you”
messages.
However, at follow-up, three months after
both types of text messages had ceased, group
differences in depression had disappeared.16
This may be because the supportive message in-
tervention had no long-lasting effect. The results
indicate the need for further investigation into
text message interventions, since the interven-
tion described above was simple, feasible, in-
expensive, and potentially highly scalable (from
individuals to large or remotely dispersed pop-
ulations).
The Mobile Principle: ‘You Don’t Need To
Be At Your Desk To Need An Answer’ Mental
health service providers should ask themselves,
“Can people in need be made aware of, and ac-
cess, mental health services when and where
S e p t em b e r 2 0 1 4 33:9 Health Affa irs 1607
Mental Health
they prefer?” With more people demanding ac-
cess to information and services wherever they
are and whenever they need it, service delivery
models must consider more distributed ways to
reach and support people. Mobile apps aimed at
improving patients’ ability to take care of them-
selves have the advantage of existing on a device
that’s already in patients’ hands at almost any
time of day.
An example of the potential effectiveness of
self-care can be found in a randomized con-
trolled clinical trial for mobile cognitive behav-
ioral therapy (CBT) for panic disorder in 2003
across sites in Scotland and Australia.30 Patients
were randomly assigned to one of four groups.
Some were put on a waiting list for therapy, some
received six weeks of standard face-to-face CBT,
and some received twelve weeks of the therapy.
The final group received six weeks of the stan-
dard therapy plus a self-guided therapy program
accessed via a mobile computing device without
telephone capability that was about the same size
as an Apple iPhone. The therapy program includ-
ed elements such as a diary module that allowed
patients to record their feelings regularly.
On each outcome measure of panic and anxi-
ety, patients using the program improved more
than those in the six-week group and less than
those in the twelve-week group. This result in-
dicates the potential for the mobile software de-
vices such as phones or phone-size computers to
create efficiencies of labor by shortening face-to-
face therapy time without harming clinical out-
comes. Additionally, people who are unwilling or
unable to participate in long-term face-to-face
therapy may benefit from access to a blend of
face-to-face and self-care options.
The Collaboration Principle: ‘Democracy
On The Web Works’ A fundamental advantage
of mobile technologies is that they give health
service providers the ability to collaborate with
patients and respond quickly to feedback.
The 2013 report on mental health from Qatar
Foundation’s World Innovation Summit for
Health31 highlighted the Viary app.32 Viary
prompts users to engage in behaviors that are
known to relieve depression, such as writing in a
journal, and tracks patients’ progress over time
and location. Patients and their therapists can
view data-based reports that help identify pat-
terns and understand triggers for depression
and setbacks to improved health. Viary can com-
bine phone sensor data and patient input data
into charts that visually present triggers; prog-
ress; setbacks; and patterns over time and across
locations, such as work and home.
A nine-week trial of Viary was conducted in
2013 at Linköping University, in Sweden.33 The
eighty-eight participants, all of whom had been
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People with common
health care concerns
find each other by
website and blog
search engines, and
through mobile apps
and Twitter tags.
diagnosed with depression, received either four
face-to-face sessions of CBT plus the use of Viary
or ten face-to-face sessions of CBT alone. Both
groups had effects of medium to large size on
measures of depression, anxiety, and quality of
life, with no significant between-group differ-
ences. This indicates that four sessions of CBT
plus Viary were as effective as ten sessions of
CBT.
This was a small study. However, it demon-
strates the potential for mobile technologies to
relieve depression.
The Speed Principle: ‘Fast Is Better Than
Slow’ Mobile technology users expect fast re-
sults from mobile text and web services and
application technology. Thus, graphics and func-
tionality must be designed accordingly. Further-
more, a mobile innovation should take up less
time than the procedure it is intended to replace.
The Primary Care Online Resources and Edu-
cation (PCORE) website of Columbia Univer-
sity’s medical school34 was launched to establish
standardized remote primary care education for
students. Before the implementation of PCORE,
Columbia did not require or provide systematic
training for students on the detection or treat-
ment of depression in primary care patients.
PCORE employed a simple design interface
and (with website development costs of about
$50,000 per module) developed an educational
tool that is fast and accessible not only via com-
puters, but also via the mobile phones and tablet
computers preferred by many students. The au-
tomated analysis of data from students’ test
scores in remote locations allows PCORE direc-
tors to monitor training progress in real time
rather than at intermittent intervals in person,
and to quickly intervene to resolve training prob-
lems early.
The User Principle: ‘Focus On The User And
All Else Will Follow’ The personal communi-

The mental health
discipline needs to
embrace evidence-
based technology and
innovations, making
effectiveness and user
engagement the top
two priorities.
cation revolution brought about by mobile
phone technologies, along with the rapidly
growing use of the Internet and social media,
has generated an expectation among users that
mobile technology products and services will be
personalized.35 Technology journalist Jeff Jarvis
concluded that in the age of the Internet and
mobile technology, “the mass market is dead,”
replaced by the mass of niches.36
How can mobile phone technology help health
care providers reach patients with the correct
information and services? Communication hubs
for niche interest groups, especially patient
groups, are found in great abundance online.
People with common health care concerns find
each other by website and blog search engines,
and through mobile apps and Twitter tags.
PTSD Coach is a self-care mobile phone app
that is available at no charge from the Depart-
ment of Veterans Affairs and mobile phone app
stores, which publish reviews and ratings from
users. The app is designed for veterans and mili-
tary service members who have or are at risk of
having post-traumatic stress disorder (PTSD). It
provides users with information about profes-
sional care, self-assessment, opportunities to
find support, and tools to manage stress in daily
life.
Customer ratings and feedback help the app’s
developers communicate directly with affected
members of the military. Publication of custom-
er reviews can increase rates of adoption by giv-
ing potential users the opportunity to read about
the acceptability of PTSD Coach by people with
whom they identify, such as other combat
veterans.
The Don’t Settle Principles “Don’t settle”
encompasses two of Google’s principles: that
“great just isn’t good enough” and that “there’s
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always more information out there.”28 Policy
makers should consider embedding evidence-
based technology interventions into accredited
training and professional development pro-
grams for mental health care providers.
On the whole, mental health services are better
developed in high-income countries than in low-
and middle-income ones.10 However, innova-
tions could further reduce future burdens to
the health system and improve access and ser-
vices in high-income countries.
We were unable to find studies on professional
resistance to evidence-based mobile mental
health tools in low-, middle-, and high-income
countries. Countries with well-developed mental
health systems may face institutional resistance
(for example, by hospital and insurance admin-
istrators) as well as professional resistance to
technological advances in mental health.37 Coun-
tries with limited or nonexistent mental health
workforces may face less resistance to innova-
tion, as professional barriers and systemic hur-
dles may not yet exist.
Research on clinicians’ attitudes toward com-
puter-assisted therapies has produced mixed re-
sults.38,39 However, there is some evidence that
clinicians are more likely to accept the use of
mobile tools for administrative functions, such
as appointment reminders, than for therapy.
Professional organizations should consider cer-
tifying mobile tools to make it easy for practi-
tioners and users to identify those that are evi-
dence based, especially for users who forgo
clinician support. This may help minimize pro-
fessional resistance to mental health mobile ap-
plications.
The Company Culture Principle: ‘You Can
Be Serious Without A Suit’ Health policy mak-
ers should not shy away from collaboration with
innovators in technology. International, evi-
dence-based alliances between the mental health
and technology disciplines will be necessary to
develop a shared understanding of how to use
mobile technology to tackle the burden of mental
health. Policy makers should promote academic
and private-sector cooperatives to foster innova-
tion in mobile technology to improve mental
health. Silicon Valley entrepreneurs and mental
health researchers in low-income countries may
not be cut from the same cloth yet, but cross-
fertilization and mutual understanding will de-
velop given the opportunity.
Global Collaboration Principles As with
“don’t settle,” “global collaboration” encom-
passes two of Google’s principles: “You can make
money without doing evil,” and “The need for
information crosses all borders.”28 Policy makers
and health service providers can build an inter-
nationally shared infrastructure of best practic-
S ep t e m b e r 20 1 4 33 : 9 Health Affairs 1609
Mental Health

es, expertise, and knowledge through coopera-
tion and sharing of development and research
costs to improve mental health technologies. The
architecture that underpins technological solu-
tions is written in the universal language of com-
puter code. This means that the underlying me-
chanics can be developed or shared by multiple
countries with limited difficulty in translation.
Instead of focusing solely on proprietary plat-
forms, policy makers should collaboratively fund
the development of open architecture that en-
dows the next generation of health professionals
not only with technology but also with institu-
tional knowledge generated from professional
insight and the analysis of data. If mHealth is
to flourish, users and other stakeholders must
set collaborative international standards for the
protection of personal health data that apply to
both the public and private sectors, including the
use of the data for research and development.
Policy makers should also consider negotiating
with telecoms and mobile data providers to de-
velop mobile and broadband networks and en-
sure the equitable distribution of mobile devices.
The number of countries with a mental health
strategy is increasing.10 However, policy makers
should collaborate across state and national bor-
ders to address the regulatory challenges of pro-
viding technology-based mental health services.
The landscape of technology interventions is
such that the patient and the professional no
longer need to be in the same area or even the
same country.
Conclusion
The evidence base for mobile interventions in
mental health is still nascent. Further clinical
research and behavior change research are need-
ed in developed countries and even more so in
developing countries. Most important, the men-
tal health discipline needs to embrace evidence-
based technology and innovations, making ef-
fectiveness and user engagement the top two
priorities. If policy makers can resolve some of
these challenges, the opportunity exists to tackle
the growing global burden of mental illness and
the increasing shortfall in the mental health care
workforce. ▪

Some of the material in this article was
previously presented at the World
Innovation Summit for Health, an
initiative of Qatar Foundation, in Doha,
Qatar, December 11, 2013. Shekhar
Saxena is an employee of the World
Health Organization (WHO). However,
the views expressed in this article do
not necessarily represent the decisions,
policy, or views of the WHO. The article
mentions some commercial
organizations, but this should not be
construed as any endorsement of these
organizations or their products. Some of
the authors can be found tweeting on
the matters discussed in this article and
more at: @mHealthTekkie (Sarah Jones);
@Imperial_IGHI (Ara Darzi); @GMental
Health (Vikram Patel); and @WISH_Qatar
(Naomi Radcliffe). The authors
acknowledge the following people for
their guidance and input: Mary De Silva
(@GMentalHealth), Will Warburton
(@Will_Warburton2), Michelle V. Hall
(@CCNMTL), and Russell Compton
Jones.

NOTES
1 Bloom DE, Cafiero ET, Jané-Llopis
E, Abrahams-Gessel S, Bloom LR,
Fathima S, et al. The global eco-
nomic burden of non-communicable
diseases [Internet]. Geneva: World
Economic Forum; 2011 Sep [cited
2014 Jul 30]. (A report by the World
Economic Forum and the Harvard
School of Public Health). Available
from: http://www3.weforum.org/
docs/WEF_Harvard_HE_Global
EconomicBurdenNon
CommunicableDiseases_2011.pdf
2 World Bank. GDP (current US$)
[Internet]. Washington (DC): World
Bank; [cited 2014 Jul 30]. Available
from: http://data.worldbank.org/
indicator/NY.GDP.MKTP.CD
3 McCrone P, Dhanasiri S, Patel A,
Knapp M, Lawton-Smith S. Paying
the price: the cost of mental health
care in England to 2026 [Internet].
London: King’s Fund; 2008 [cited
2014 Jul 30]. Available from: http://
www.kingsfund.org.uk/sites/files/
kf/Paying-the-Price-the-cost-of-
mental-health-care-England-2026-
McCrone-Dhanasiri-Patel-Knapp-
Lawton-Smith-Kings-Fund-May-
2008_0.pdf
4 Layard R, Clark D. Thrive. London:
Penguin Publishing; 2014. p. 179.
5 Layard R, Clark D, Knapp M, Mayraz
G. Cost-benefit analysis of psycho-
logical therapy. Natl Inst Econ Rev.
2007;202(1):90–8.
6 Layard R. Mental health: the new
frontier for labour economics. IZA
Journal of Labor Policy. 2013;2(2).
7 Scheffler RM, Bruckner TA, Fulton
BD, Yoon J, Shen G, Chisholm D,
et al. Human resources for mental
health: workforce shortages in low-
and middle-income countries.
Geneva: World Health Organization;
2011 [cited 2014 Jul 30]. Available
from: http://whqlibdoc.who.int/
publications/2011/9789241501019_
eng.pdf?ua=1
8 World Health Organization. Mental
health atlas 2011. Geneva: WHO;
2011.
9 World Health Organization. The
world health report 2000—health
systems: improving performance.
Geneva: WHO; 2000.
10 Patel V, Weiss HA, Chowdhary N,
Naik S, Pednekar S, Chatterjee S,
et al. Lay health worker led inter-
vention for depressive and anxiety
disorders in India: impact on clinical
and disability outcomes over
12 months. Br J Psychiatry. 2011;
199(6):459–66.
11 Van Schaik DJ, Klijn AF, van Hout
HP, van Marwijk HW, Beekman AT,
de Haan M, et al. Patients’ prefer-
ences in the treatment of depressive
disorder in primary care. Gen Hosp
Psychiatry. 2004;26(3):184–9.
12 World Health Organization.
mHealth: new horizons for health
through mobile technologies: based
on the findings of the Second Global
Survey on eHealth [Internet].
Geneva: WHO; 2011 [cited 2014
Jul 30]. Available from: http://
www.who.int/goe/publications/
goe_mhealth_web.pdf
13 Nundy S, Dick JJ, Chou CH, Nocon
RS, Chin MH, Peek ME. Mobile
phone diabetes project led to im-
proved glycemic control and net
savings for Chicago plan partici-

1610 H e a lt h A f fai r s S ep t e m b e r 20 1 4 33 : 9
Downloaded from content.healthaffairs.org by Health Affairs on September 9, 2014
at GALTER HEALTH SCI LIB, NORTHWESTERN UNIV.
 pants. Health Aff (Millwood). 2014;
33(2):265–72.
14 Depp CA, Mausbach B, Granholm E,
Cardenas V, Ben-Zeev D, Patterson
TL, et al. Mobile interventions for
severe mental illness: design and
preliminary data from three ap-
proaches. J Nerv Ment Dis. 2010;
198(10):715–21.
15 Agyapong VI, Ahern S, McLoughlin
DM, Farren CK. Supportive text
messaging for depression and co-
morbid alcohol use disorder: single-
blind randomised trial. J Affect Dis-
ord. 2012;141(2–3):168–76.
16 Agyapong VI, McLoughlin DM,
Farren CK. Six-months outcomes of
a randomised trial of supportive text
messaging for depression and co-
morbid alcohol use disorder. J Affect
Disord. 2013;151(1):100–4.
17 World Health Organization. Mental
health action plan 2013–2020.
Geneva: WHO; 2013.
18 Wesolowski A, Eagle N, Noor AM,
Snow RW, Buckee CO. Heteroge-
neous mobile phone ownership and
usage patterns in Kenya. PLoS One.
2012;7(4):e35319.
19 Broadband Commission. The state of
broadband 2013: universalizing
broadband [Internet]. Geneva: The
Commission; 2013 Sep [cited 2014
Jul 30]. Available from: http://
www.broadbandcommission.org/
documents/bb-annualreport2013
.pdf
20 To access the Appendix, click on the
Appendix link in the box to the right
of the article online.
21 Lewis T, Synowiec C, Lagomarsino
G, Schweitzera J. E-health in low-
and middle-income countries: find-
ings from the Center for Health
Market Innovations. Bull World
Health Organ. 2012;90(5):332–40.
22 Free C, Phillips G, Watson L, Galli L,
Felix L, Edwards P, et al. The effec-
tiveness of mobile-health technolo-
gies to improve health care service
delivery processes: a systematic re-
Downloaded from content.healthaffairs.org by Health Affairs on September 9, 2014
view and meta-analysis. PLoS Med.
2013;10(1):e1001363.
23 Qiang CZ, Yamamichi M, Hausman
V, Altman D. Mobile applications for
the health sector [Internet]. Wash-
ington (DC): World Bank; 2011 Dec
[cited 2014 Jul 30]. Available from:
http://siteresources.worldbank.org/
INFORMATIONAND
COMMUNICATIONAND
TECHNOLOGIES/Resources/
mHealth_report.pdf
24 Harrison V, Proudfoot J, Wee PP,
Parker G, Pavlovic DH,
Manicavasagar V. Mobile mental
health: review of the emerging field
and proof of concept study. J Ment
Health. 2011;20(6):509–24.
25 Proudfoot J. The future is in our
hands: the role of mobile phones in
the prevention and management of
mental disorders. Aust N Z J Psy-
chiatry. 2013;47(2):111–3.
26 Proudfoot J, Parker G, Hadzi
Pavlovic D, Manicavasagar V, Adler
E, Whitton A. Community attitudes
to the appropriation of mobile
phones for monitoring and manag-
ing depression, anxiety, and stress. J
Med Internet Res. 2010;12(5):e64.
27 Drucker P. Innovation and entre-
preneurship. 4th ed. New York:
Routledge; 2011.
28 Google. Ten things we know to be
true [Internet]. Mountain View
(CA): Google; [cited 2014 Jul 30].
Available from: http://www.google
.com/intl/uk-EN/about/company/
philosophy
29 Carper MM, McHugh RK, Barlow
DH. The dissemination of computer-
based psychological treatment: a
preliminary analysis of patient and
clinician perceptions. Adm Policy
Ment Health. 2013;40(2):87–95.
30 Kenardy JA, Dow MG, Johnston DW,
Newman MG, Thomson A, Taylor
CB. A comparison of delivery meth-
ods of cognitive-behavioral therapy
for panic disorder: an international
multicenter trial. J Consult Clin
at GALTER HEALTH SCI LIB, NORTHWESTERN UNIV.
Psychol. 2003;71(6):1068–75.
31 Patel V, Saxena S, De Silva M,
Samele C. Transforming lives, en-
hancing communities: innovations
in mental health. Doha: Qatar
Foundation; 2013.
32 Viary [home page on the Internet].
Stockholm: Viary [cited 2014 Jul 30].
Available from: https://www.viary
.se/
33 Hoa’s Tool Shop. Our app made CBT
treatment for depression twice as
effective [Internet]. Linköping
(Sweden): Hoa’s Tool Shop; [cited
2014 Aug 6]. Available from: http://
www.hoastoolshop.com/our-app-
made-cbt-treatment-for-depression-
twice-as-effective/
34 Columbia University. Primary Care
Online Resources and Education
[home page on the Internet]. New
York (NY): Columbia University;
[cited 2014 Jul 30]. Available from:
http://pcore.ccnmtl.columbia.edu
35 Campbell SW, Park YJ. Social im-
plications of mobile telephony: the
rise of personal communication
society. Sociol Compass. 2008;2(2):
371–87.
36 Jarvis J. What would Google do? New
York (NY): Collins Business; 2009.
p. 207.
37 Andrewes H, Kenicer D, McClay CA,
Williams C. A national survey of the
infrastructure and IT policies re-
quired to deliver computerised cog-
nitive behavioural therapy in the
English NHS. BMJ Open. 2013;3(2).
38 Becker EM, Jensen-Doss A. Com-
puter-assisted therapies: examina-
tion of therapist-level barriers to
their use. Behav Ther. 2013;44(4):
614–24.
39 Stallard P, Richardson T, Velleman
S. Clinicians’ attitudes towards the
use of computerized cognitive be-
haviour therapy (cCBT) with chil-
dren and adolescents. Behav Cogn
Psychother. 2010;38(5):545–60.
September 2014 33:9 Health Affairs 1611