Can Psychology Apps Help the Health System?

With greater pressure placed on public health systems—due to increased life expectancy and poor life-style choices—governments are turning to technology to ease the burden. Many leaders have suggested that utilising digital technologies may be a way forward. New research shows that such platforms benefit psychological support for health behaviours, but that it’s also important to assess potential risk. Will the harms outweigh the benefits?

Recently, a widely-publicised research study conducted by Apple Watch suggested that exercise behaviours could be increased by participants using an app on a smartwatch. 1 The app monitored their activity, and, if they reached certain exercise goals, they did not have to pay a monthly fee for the smartwatch. In fact, those participants who used the app exercised significantly more than those who did not. The increased level of exercise attributed to the use of the app, and its motivation to exercise, was said to be the equivalent of an extra two years of life. The study seems to be a reasonable one, and this is good news for the innovative use of a platform to deliver a reward-based system.

The UK Minister for health, Matt Hancock, seems to agree 1,2 : “We’re better off and healthier because of technological progress…That’s why I believe in tech…and I’m optimistic that with the right tools in the NHS we can improve people’s lives by improving people’s health.” 1

So far, so good. However, there are a number of issues that we should think carefully about before adding exercise apps to the list of potential positives to arise from digital technology, and further strengthen the hand of those who believe that this is the future of health care.

We should remember that the reward system employed in this study was essentially one motivated by negative reinforcement; participants were rewarded for avoiding something nasty. In this case, the participants who reached their exercise targets were not charged money. It has long been known, since Skinner’s analysis of punishment, that this form of aversive control will eventually lead to negative emotions, and to attempts to counter-control the controller. 3 The easiest way to counter-control in this instance is simply to not sign up for the monthly fees that come with the watch—by far the easiest way to save the money in the first place!

Repeat: I am not a short-order cook. "It's a child's job to learn to eat what the parents eat," says Ellyn Satter, a registered dietitian and the author of Secrets of Feeding a Healthy Family. Instead of the all-or-nothing scenario, offer a variety of foods at mealtime: the main course, plus rice or pasta, a fruit or vegetable, and milk. This way, your child can eat just the pasta and the peas and get protein from the milk. "What a child eats over the course of a day or a week is more important than a balanced meal at one sitting," says Stephen Daniels, the chairman of the department of pediatrics at the University of Colorado School of Medicine, in Aurora.

Of course, it can be countered that there are many other apps that also come with fees, not just the exercise monitor, and exercising buys you access to these apps for free. However, herein lies the real potential problem. What are the effects of all of those other apps on the person’s psychological and physical health?

There is increasing evidence that over-use of digital technologies such as smartphones can be detrimental to people’s mental and physical health. Some studies have shown a link between over-use of digital technology and harmful effects on the immune system, such as that published by myself and colleagues in PLOS ONE in 2015, 4 and others have shown that overuse of such technology is associated with poor lifestyle choices (bad diet, poor sleep). 5 How these negative influences interact with the benefits of exercise remains to be seen.

Leaving aside the direct problematic effects of such technology on health, many other studies have suggested a clear link between mental health concerns and the over-use of digital technology. Ultimately, it is this association that may be the most troubling for the use of smartwatch apps, and the like, to promote health. The more we promote people using their apps, then the more likely we are to see a rise in such mental health problems. If we are talking in terms of life expectancy, then an equally good study as the Apple Watch study, charting the benefits of smartwatch exercise apps, was conducted by Chesney, Goodwin, and Fazel and published in 2014 in World Psychiatry. This study found that depression can take 11 years off a person’s life expectancy—just as much as smoking. Indeed, all mental health problems negatively impact life expectancy. So, in the context of a digital exercise app, a possible 2 years gained for a possible 11 years lost doesn’t seem like a good deal by any standards.

Know the value of face-to-face communication. Very young children learn best through two-way communication. Engaging in back-and-forth "talk time" is critical for language development. Conversations can be face-to-face or, if necessary, by video chat with a traveling parent or far-away grandparent. Research has shown that it's that "back-and-forth conversation" that improves language skills—much more so than "passive" listening or one-way interaction with a screen.

Now, here are the imponderables. How many people get the benefit, and how many get the harms? How do these multiple impacts interact with one another—does the exercise rush overcome the depressive tendencies, or does the depression swamp the motivation to exercise? Can we more clearly identify the ‘whos’ and ‘whys’ associated with these benefits and harms?

Until the answers to these questions emerge more clearly, then it may well be prudent to refrain from a headlong rush into digital health care. For all we know, it’s like saying nicotine improves your attention, so here, have a cigarette!