Response to ‘Use of mobile technology in a community mental health setting’

Dear Editor,

We read the paper entitled ‘Use of mobile technology in a community mental health setting’ by Glick et al. with interest. ¹ The authors highlight the opportunity mHealth creates and draws attention to how various patient groups have different needs and challenges with this new mode of communication. This paper is both timely and important. mHealth interventions are being developed across the world but their ability to integrate with varying patient populations has not been properly looked into. ² Looking at the use and penetrance of smartphone and mobile phone uptake in different patient groups, in this case the mental health population, will thus be hugely beneficial to developers of mHealth solutions.

This paper concludes that patients with a serious mental illness are less likely to own a mobile phone or smartphone when compared to the general population. It states that even though mobile technology can improve self-management, barriers such as cost prevent the mental health population from taking advantage of the technology. This could lead to developers being less likely to develop for this group; however, there are certainly aspects that need to be clarified before taking these findings at face value.

Firstly, this is a single-centre study of only 100 patients, leading to questions over the ability to extend these findings to the psychiatric patient population as a whole. The authors did not perform a power calculation and it is unlikely that this sample is sufficient in size. Population demographics will differ considerably and so large samples, preferably multi-centre, are important to draw meaningful conclusions on the impact that mental health illness will have on the likelihood of mobile phone or smartphone ownership. As many mHealth interventions are not developed for just one centre, this makes the process even more important.

Furthermore, the authors compare their sample to the general population gathered in the Pew survey to draw their conclusions on the impact of mental health on mobile use. However, the background demographics of the two samples vary considerably. The authors’ sample was more likely to be poorer with 82% with an annual income less than $10,000 (vs 10%) and were nearly 2x more likely to have a lower education with less than 12 years of schooling (81% vs 44%). ¹ Furthermore, since participants were compensated for their time, they are perhaps more likely to be of lower socioeconomic group. ³ The Pew survey from that year shows that lower income and lower education individuals are less likely to own a smartphone, ⁴ and even though serious mental illness may be more common in these groups, the authors did not properly take these differences into account. These factors may have contributed to the discrepancy in mobile phone ownership between the study and general population and mask the actual difference between the two populations.

Finally, at no point do the authors make clear that they defined ‘smartphone’ to the patient group. One definition of smartphones by the US Federal Communications Commission (FFC) are mobile devices capable of ‘easy access to the … internet; an operating system that provides a standardized interface and platform for application developers … and a larger screen size than a traditional handset’, ⁵ whereas another by Ozdalga et al. defines it as ‘any cellular device [with] additional functions [such as] a camera’. ⁶ This shows that there can be some discrepancy on exact definitions and as 48% of the patients’ surveyed use the internet on their phone it is quite possible to say a higher proportion than 37% own a smartphone. This is important to define as many mHealth interventions rely on smartphone capabilities such as an internet connection and will mean their ownership values for smartphones become unreliable due to the possible variance in patient understandings of what the smartphone definition includes.

With the increasing burden of chronic conditions on health systems across the world, mHealth has been heralded as one of the solutions in dealing with the increasing demand. ² However, most mHealth solutions are being created with a top–down mentality, not observing the needs or capabilities of the patient population. To ensure best value for money and optimum uptake and success of these innovations, it is crucial to properly understand the penetrance and use of mobile devices in multiple patient groups and direct these interventions to the patient groups with most desire for them. Furthermore, smartphone penetrance alone will not ensure acceptance and uptake of a mobile health solution. More research needs to be done to identify why certain patient groups are more accepting of an intervention and what factors yield success in the continued use of mHealth. This will help guide developers and healthcare professionals in their use and commissioning of patient-facing mHealth programmes.

This study is an important piece of research but one which needs to be repeated with an improved protocol and larger sample size in various patient groups. mHealth could improve self-management whilst reducing the cost for many healthcare services but further enquiry is required to ensure it achieve maximum success in the most appropriate patient populations.