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Mobile health (mHealth) in mental health: Scope and applications in low-resource settings
2 Department of Psychiatry, Indraprastha Institute of Information Technology, Okhla Industrial Estate, New Delhi 110020, India
All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029
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Sood M, Chadda RK, Singh P. Mobile health (mHealth) in mental health: Scope and applications in low-resource settings. Natl Med J India 2016;29:341-343
Mobile health (mHealth) is a component of eHealth. It has been defined by the Global Observatory for eHealth as medical and public health practice supported by mobile devices such as mobile phones, patient monitoring devices, personal digital assistants (PDAs) and other wireless equipment.  Mobile technologies have spread rapidly across the world and are being used in various fields of healthcare such as maternal and child health, tuberculosis and HIV. In recent years, these technologies have also been used to assess and manage various mental disorders. The lower cost and multiple functions of mobile phones have led to their use at a larger scale than other mobile devices such as patient monitoring devices and PDAs. Few studies have used PDAs in mental health,  but mobile phones have mainly been used in mHealth in the mental health sector.
Globally, about 7 billion people live in an area covered by a mobile-cellular network and 84% of the population is covered by mobile broadband networks.  Unlike traditional health services, mobile phones do not require physical proximity of health providers and can deliver services at a clinic or home or fixed basic physical structures (telephone, internet or telemedicine-based services) such as telephone connection and handset or a personal computer and internet connection.  Also, users do not have to learn new skills, since many people who have no access to computers or internet connection use mobile phones to get information and access various services. Mobile phone technologies offer choices for healthcare delivery that are cheap, user-friendly and use the existing infrastructure. Mobile phones with their ubiquitous presence, portability, increasingly better computational capacities at a cheaper cost, and internet connectivity make them an ideal platform for healthcare applications.  ,
Mainly high-income countries have done research in mHealth. Though low- and middle-income (LAMI) countries lack resources, they have seen remarkable penetration of mobile technology. In India, there are 971 million wireless telephones with a teledensity of 77.6% and a share of 97.2% of total telephones.  mHealth has the potential to become an important service link between the meagre mental health services and unfulfilled mental healthcare needs of the vast majority of unreached patients and caregivers. We discuss the scope and application of mobile phones in mental health in low-resource settings.
Use Of Mobile Phones In Mental Health
Mobile phone technologies can complement and supplement clinic or home-based care by their ability to deliver mental health services outside the clinic. Most (72%-97%) patients with mental illness have reported the use of mobile phones for activities other than spoken conversations such as sending emails, web browsing and social networking.  , , Smartphones are increasing faster than basic phones. 
Broadly, mobile phones are of two types: feature phones and smartphones. The former has functions such as voice calling, text messaging, basic multimedia and internet capabilities, whereas the latter combine functions of a personal computer and can run a variety of applications such as access to the internet, touch screen user interface, media player, camera phone, navigation unit for global positioning system (GPS) and motion sensors. Mobile phone technologies in mental health use short message service (SMS), within application notifications, voice messaging or video and vary according to the level of interaction between the clinician and the patient, which can be live, asynchronous or autonomous.  , Mobile phone technologies can be standardized or tailored to user data, which may be acquired as stored recorded data in a mobile device or ecological momentary assessment as a record of a patient′s real-time experiences. The recorded data can be stored locally on the device or uploaded to a centralized server. 
In high-income countries, mobile phones have been used to evaluate and manage different aspects of psychiatric disorders. The use of mobile phones for evaluation includes assessment of symptoms and medication adherence, comparing ecological momentary assessments recorded in real time on mobile phones and retrospective reports, identifying relapse and its early treatment, and prompting health-promoting behaviour.  , , , , , , , , , SMS has also been used as an adjunct to phone-based psychotherapy in crisis situations  and in cognitive behaviour therapy for depression and cessation of smoking. 
Research on mobile technologies includes short-term project-based studies by mental health and technology professionals mostly from high-income countries. Most of these interventions have been designed for use by patients. Research has shown the feasibility, acceptability and utility of mobile-based technologies for implementing psychosocial interventions in various mental illnesses.  , ,
Limitations of mHealth include (i) how to use huge data generated by these devices; (ii) whether consumers will accept 24x7 interactions with mobile technologies; (iii) how to develop interventions for persons at high risk for self-harm and other psychiatric emergencies; (iv) difficulties in making and implementing mobile-based protocols; and (v) the issue of data protection and confidentiality.
Scope In Low-Resource Settings
In LAMI countries, there is a gross mismatch between mental health morbidity, and funds and resources allocated to mental health. For example, in India, with lifetime prevalence of 13.7%, nearly 150 million persons above the age of 18 years need active intervention for psychiatric disorders.  However, mental health gets only 0.06% of the total health budget.  Most patients with psychiatric disorders seeking treatment in LAMI countries receive only pharmacological treatment, and negligible psychosocial interventions due to shortage of non-medical mental health professionals.  , In a survey, 88% of patients attending outpatient services at the authors′ institute were using mobile phones regularly.  The mobile phone is used mostly for making and receiving phone calls. Other usage included sending and receiving short text messages (68%), clock and alarm functionalities (49%), recreational activities (39%) and accessing social network sites (30%). Most people felt that mobile phones can be used as an aid in the treatment of psychiatric disorders for sending reminders for appointments and taking medications, and for receiving educational messages.
In LAMI countries like India, feature phones are more widely available and are cheaper (1000-1500), though have limited functions. However, these can be used to provide SMS-based interventions. The costlier (≥4000) smartphones can be used for more sophisticated interventions.
Mobile phone technologies, especially SMS-based messages in local languages, can be used for increasing awareness about various aspects of mHealth and mental illnesses. The messages may include early signs of mental illness, need for treatment, where to seek help and from whom, kinds of treatment available, simple psychosocial measures important for recovery and how long to continue treatment. Similar messages regarding alcohol and drug use disorders can be used. The technology can promote positive mental health such as improving sleep hygiene, lifestyle modification and how to say no to drugs. These educational messages can also be targeted at the general population. For special population groups such as women, school- and college-going children and adolescents, and the elderly, messages can be tailored to their needs. Bulk messages on special days such as the world mental health day can also be sent. Women and their caregivers can be sent messages regarding identification and management strategies for postpartum blues. This can help in reducing stigma related to mental illnesses and seeking treatment.
Mobile phone-based applications can be used for training medical, nursing and paramedical students, primary care physicians and health workers. These can also be used to sensitize teachers in schools and colleges to identify mental illnesses in their students and seek help. There is potential for their use in workplaces. Similar applications in vernacular languages can be used to train anganwadi workers.
Linking tertiary care centres with primary and secondary care centres
Service providers in primary healthcare centres can be linked with secondary and tertiary care centres using mobile phone technology for seeking opinion, appointment and management. Phone service over the internet such as Skype can be used to provide telepsychiatry services at a cheaper cost in contrast to the traditional telemedicine facilities which require elaborate infrastructure at both ends.  This model can be used to link a psychiatrist in a tertiary care centre to patients at primary and secondary care centres.
Mobile phone technologies have been used to assess and manage patients with mental illnesses in high-income countries. However, protocols from high-income countries may not be suitable for use in LAMI countries due to differences in quality and quantity of mental health resources and the prevailing sociocultural norms. In high-income countries, mobile technology protocols for psychosocial interventions have been designed and implemented in the context of sociocultural expectation that adults after a certain age live independently and not with their families. High-income countries have a well-developed community care service in the form of social workers, case managers, support for vocation, housing and education, and social security benefits, all geared towards making the patient stay independently. In contrast, in low-resource settings such as India, due to lack of community care services, families play an important role in initiating treatment, procuring and supervising medicines to providing psychosocial support to patients with mental health problems.  Thus, in low-resource settings, mobile phone technology protocols would also need to be designed for caregivers along with patients.
Psychosocial interventions are an important mode of treatment for common mental disorders and form a crucial link between reduction of symptoms and recovery for patients with severe mental disorders. In the context of low mental health resources, providing psychosocial interventions is a challenge, and can be addressed by using increasingly efficient, convenient and affordable mobile phone technologies (with deep penetration into the population) with availability of vernacular languages on android platforms. Integration of these technologies with clinic-based services may help to bridge the gap between services and users, and may also offer individualized and cost-effective psychosocial interventions. Mobile phone technologies may offer greater flexibility in the duration, timing and setting of interventions, and reduce number and duration of face-to-face sessions, which may translate to reduced costs. 
In LAMI countries, most mental health services are concentrated in tertiary care centres situated in urban areas. Many patients with their caregivers travel long distances to seek psychiatric help with one or more family members. The instant messaging service can be used to upload key points related to a drug (name, dose, duration) and psychosocial treatment (sleep hygiene, activity scheduling, need for resuming work, no alcohol, etc.) to the family members at home who may be the chief caregiver for the patient and whose understanding about the illness and its treatment is crucial to a good outcome.
Social networking sites and WhatsApp messenger-like platforms have the potential to form caregivers′ support groups at the local and national levels. Similar groups can be formed among various stakeholders.
Mobile phone technologies can also help in conducting surveys using simple questionnaires among a large population spread over different geographical locations. Psychosocial interventions could be assessed with real-time data, and thus can be a useful input for research.
There have been few initiatives in using mHealth in mental health in India. Open-source mobile technologies have been used in Kashmir to collect data on prevalence of depression, anxiety and post-traumatic stress disorder.  A Cloud-based mental health platform has been designed to connect rural populations with specialist care through community mental health workers.  Mental health services have also been extended to university students in India. 
Mobile phones are increasingly being used to get mental health information and other services on the internet. Integration of mobile phone technologies with clinic-based services can bridge the gap between services and users and may help in providing psychosocial interventions. Efficient, convenient and affordable mobile technologies may also be used in increasing awareness about mental illnesses in the population and linking personnel in primary care centres with secondary and tertiary care services. mHealth protocols designed for mental healthcare should focus on caregivers as they remain a crucial resource in the absence of facilities for community-based care in low-resource settings.
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