Using an app to combat mental illness

Since December 2020, apps have been available on prescription. But in order to be officially listed as a health app, start-ups have to meet many requirements. Insights into two young companies that want to hold their own in the highly sensitive field of psychology, of all things.

The psyche is suffering. Not just since the Corona pandemic, but long before. Between 2010 and 2020, the number of days absent due to mental illness in Germany increased by 56 percent, according to the current psych report of the health insurance company DAK. But sufferers often wait months for a place in therapy.

It is a gap that should not exist in Germany. But because mental illnesses are on the rise and there are too few therapy places at the same time, the waiting times are getting longer and longer. This seems tailor-made for start-ups that can help patients in the short term with digital applications. But many young companies are finding it difficult to hold their own on the market in the long term.

In addition to freely available apps that advertise help for psychological upsets, since December 2020 patients have also had the option of relying on a Digital Health Application (DiGa), which a doctor prescribes by prescription. Who gets on the list is decided by the Federal Institute for Drugs and Medical Devices (BfArM). In order to be allowed to offer such a service, start-ups must prove compliance with standards such as data protection and suitability for users within three months. Then they are provisionally admitted.

For "permanent" status, they must submit a randomised controlled trial on the effectiveness of their offer. At this point at the latest, many start-ups fail. Between May 2020 and January 2021, 25 manufacturers of a DiGa withdrew their application for inclusion in the federal government's directory because they could not sufficiently demonstrate quality, function, or privacy.

Hanne Horvath is one of the founders currently trying to meet all the requirements for permanent listing. She launched her venture in December 2020 with her startup HelloBetter, and now the review process is underway. HelloBetter has a wide range of ten online programs that support people with, for example, depression, anxiety disorders or burnout. The start-up is successful even without being listed: "Our user numbers have tripled in the last year," says psychologist Horvath. Some health insurers already cover the cost of the programs.

But what exactly do users of the app get? "We're all about helping people make lasting changes to their daily lives, and that's something that's incredibly difficult," Horvath explains. To do this, the programs include breathing techniques, relaxation exercises, strategies against rumination, and other elements from cognitive behavioral therapy. There is also a digital diary. Psychologists accompany users throughout the training and provide written feedback on progress after each session. "This is also for reasons of patient safety: we can't just rely on the program when it comes to depressives, for example, whose symptoms are getting worse. That's where human guidance is critical," Horvath says. Professionals recognize warning signs, contact those affected and offer help.

But Hovarth says the eight- or six-week programs are only meant to supplement or tide people over while they wait for a therapy slot, not replace it. Digital services, he said, are readily available, unlimited in capacity and less barrier-free for those affected, as they don't require phone calls or initial interviews. "We can often pick people up very early, at times when they're not ready to talk to doctors or psychotherapists or disclose."

There are currently 15 DiGas in the directory, providing services in areas such as cardiology, neurology, ear, nose and throat, and mental illness.

One, of the permanently incorporated applications, is the Deprexis therapy program, launched in February 2021. The offer comes from the manufacturer Gaia, which has also developed other listed applications in the DiGa directory. Distribution is handled by others; in the case of Deprexis, it is the German branch of the French pharmaceutical company Servier. Deprexis offers the method of cognitive behavioural therapy, also known in analogue therapy, for sufferers of depression: "Our program is determined by a fixed algorithm. As a user, you answer questions that become more refined and individualized, like a tree," explains Michael Keil, Medical Information Senior Project Manager at Servier. There are exercises, audio clips and the teaching of techniques for dealing with depressive moods and depression. Keil stresses that an accurate diagnosis by doctors is always crucial for the programs to be effective.

The digital offering from Deprexis is primarily intended to become a companion in everyday life that provides support and also reminds users when they have not done any exercises for a long time: "We receive reports that patients have developed a kind of relationship with the programs," says Keil. For example, they wanted to continue receiving text messages and e-mails after completing treatment, asking, for example, which thoughts were positive today, which were negative, and when the last nice moment was.

A problem that both Deprexis and HelloBetter and all the other applications have: They're not particularly well known. Not with potential users, not in the offices of doctors who can print DiGas on prescriptions. Companies like Deprexis have the advantage of having a pharmaceutical company behind them to market through existing contacts. Others try to gain notoriety through advertising campaigns on social networks: Berlin-based start-up Selfaply, for example, recently collaborated with entrepreneur and influencer Madeleine Alizadeh, who promoted its digital therapy offering on Instagram.