Design and development of a mobile-based self-care application for patients with depression and anxiety disorders

In this study, a mobile-based self-care application was designed and developed for patients with depression and anxiety disorders. The designed application allows the patient to register and enter through a username and password and record their clinical history in PDF format and send it to the doctor. Also, this app can help to improve patients’ lifestyles by providing educational information on reducing and controlling anxiety and depression in the form of videos, text and voice. Moreover, management of medications dose and time of use, the ability to record activities, personal goals and habits in a diary, the introduction of depression and anxiety treatment centers, communication with other patients and doctors were other features of this application. Wasil R et al. [51] reviewed applications were designed for depressive and anxiety disorders in a review study. The most common features used in these applications included educational and self-assessment services to patients, how to gain calm, concentration and meditation. Also, in our study, educational services were provided to improve self-care processes and how to achieve relaxation, concentration and meditation. Instructions for concentration and relaxation let person to get rid of internal and external factors that bother him/her. These instructions can help people to return to a normal state and perform daily routine activities in the present [52] and reduce stress and anxiety in people with depressive and anxiety disorders [53‐55].

Fuller-Tyszkiewicz et al. [56] also designed a self-monitoring application with name BlueWatch to improve the well-being of adults with depressive symptoms. This app is organized based on the principles of Cognitive Behavioral Therapy (CBT) in six modules of psychological education about depression and an introduction to CBT, behavioral activation, cognitive reconstruction, problem-solving skills, assertiveness, and treatment methods to prevent Recurrence of disease. Blue Watch features also included short audio education activities, daily practice and self-monitoring functions (using daily mood recordings), short welcome video, training with the app and dashboard (to store patient activities and texts). The present study provides daily exercises in the form of relaxation instructions in the designed application. Patients by performing daily exercises such as calm and regular breathing, muscle strengthening, prayer, music therapy, aromatherapy, mental imagery, mindfulness, meditation, walking with mindfulness or yoga, repeating soothing words help themselves to reduce stress and anxiety.

Management of smoking, shisha, alcohol and drugs was another feature of the application designed in our study. Deady et al. [57] also were considered a section for managing of smoking, hookahs, alcohol, and drugs in their application, along with other information-educational needs and capabilities such as training programs (prevention of exacerbation of effects of anxiety and depression disorders, overcoming stress and negative thoughts, how to get away from relationships and stressful environments) relaxation instruction, sleep management, physical activity and exercise, and daily programming. Other studies [58‐60] have shown that there is a direct link between depression and anxiety and smoking. They can increase the severity of anxiety and depression in these patients over the time. So, in self-care applications for these patients, it is better to allocate a section for smoking, shisha, alcohol management.

Patient management of medications was another feature of the application designed in the present study. This feature can help patients to enter the name of the drug, dosage, drug allergies and drug use date. In order to take the medicine, the necessary warnings were given to the patient according to the time and date of use. Philip Kaare Løventoft et al. [61] designed an application called life management to support patients with depression. This application has various capabilities for user registration, measuring the patient’s depression based on the WHO Major Depression Inventory (MDI) questionnaire, Mood, appetite and sleep registration, calendar and event types, location tracking and mapping (providing data on patient movement patterns for Predicting phases of depression) and routine management (to help users with daily tasks such as getting out of bed, taking a shower, and daily programming). Also, it had capabilities to record a list of drugs that could be edited by the user, reminding the use of drugs in the Medication management section.

In evaluating a mobile application, there are always problems, advantages and disadvantages, which will be analyzed in the following. Furthermore, Wei and et al. [62], underscored the significance of an interactive process that didn’t bewilder users or require numerous iterations for comprehension, as such hurdles hindered their sustained engagement with the application. For example, offering clear explanations of how the mHealth intervention operated, including guidance on what steps to take next, encouraged ongoing usage.

The unwillingness of patients [63, 64] to cooperate in the evaluation process is one of the major issues with evaluating mobile applications. Patients’ lack of knowledge and awareness of the advantages and uses of these applications, as well as a lack of sufficient evidence regarding the effectiveness of anxiety and stress applications, may also contribute to their unwillingness to cooperate. Therefore, ways to encourage patient cooperation should be offered. One of these solutions is to give patients adequate information about the utility and efficacy of the application. The application’s adoption and use, as well as collaboration, can all be enhanced by this solution. Additionally, inviting patients from different races, ethnicities, genders, ages, and education statuses to a meeting of the research team to discuss this application and its advantages can be helpful [65]. If patients are made aware that self-care tools may aid in illness management and control. Then, it will be simpler for patients to embrace these apps since they would think that by following self-care the applications, their recovery will be substantially accelerated [64, 66, 67]. The team can highlight the advantages of an anxiety and depression self-care app, like better health information access‌ [68], lower medical errors and treatment costs, improved coordination among healthcare providers, and reduced patient travel [69]. They can also inform patients that the app offers greater flexibility, enabling them to spend less time at treatment centers and more time on daily tasks [70].

Privacy concerns during patient evaluations are another issue that has been identified in prior research [71‐73]. Designers of applications should strive to keep patient information private. Therefore, each patient must have a unique username and password for self-care applications. In addition, the research team should provide sufficient assurance to the patients that the information they enter will remain confidential while using the application. The ease of use of self-care applications is another patient concern [74, 75]. This issue can be resolved by providing patients with the necessary training in the form of multiple training sessions, as well as by preparing educational files in the form of video and text regarding the use of the application for patients and doctors [24].

Another issue in mobile application evaluation is the availability of various evaluation tools (questionnaires such as mobile app rating scale (MARS) and system usability scale (SUS), heuristic evaluation, think aloud, etc.) and the lack of flexibility of these tools. For instance, Zhou et al. [76], argued that the SUS questionnaire, when applied to aspects unique to mobile apps, fails to yield the specific information required for evaluating mobile applications effectively, highlighting the need for tailored evaluation tools in the mobile app domain. To solve this issue, the primary objective of each research’s evaluation should be identified, and then the right tool should be chosen. The tool selected for evaluation should focus on various dimensions related to evaluation quality, readability and cultural sensitivity of content, usability and features of health applications [77]. Another drawback of application evaluation studies is the length of time needed to complete the evaluation. A mobile application may initially appeal to the patient and the therapist in a way that yields a positive initial evaluation result, but over time, the outcome changes. As a result, it is preferable to evaluate over time. It should be noted that imbalances in access to online health care systems that are a reflection of well-known socioeconomic disparities in access to online services. The same factor makes using mobile devices for remote service delivery to rely on patients who have more facilities and skills and may unjustly burden those who are less able with treatment using newer technologies [78]. One of the difficulties that evaluators encounter when assessing applications for anxiety and stress management programs is this disparity. In this case, researchers may decide to exclude study participants who lack smart phones, internet access, adequate bandwidth, a sufficient level of literacy, or the desire to take part in the study.

App evaluation can also have benefits. Different aspects of an application are examined in different ways during evaluations. For instance, the following three factors are taken into account and scrutinized during the usability evaluation: (1) Having greater usability, (2) more user satisfaction (meets the user’s expectations), and (3) easier learning (the operation can be learned very quickly by observation). Or, ten indicators are highlighted in Nielsen’s assessment: (1) display Visibility of system status, (2) consistency and standards, (3) user control and freedom, (4) error prevention, (5) recognition rather than recall, 6) flexibility and efficiency of use, (7) flexibility and efficiency of use, (8) aesthetic and minimalist design, (9) honesty in expressing mistakes and providing solutions - assisting users in identifying, analyzing, and resolving errors; and (10) assistance and documentation [79, 80]. The design team will identify and address any issues with these dimensions after evaluating the application. A user-friendly application will subsequently be created for users. However, once all the issues are resolved, the patients’ continued use of the application will increase. Patients will be less satisfied and use these applications less if an application is not usable or does not have the necessary quality for the patient’s goals [81]. According to some studies [82, 83], users will be dissatisfied with the application if there are potential delays in their response to the application, a lack of optimal speed for the information and content it contains, difficulty in learning and comprehending its features. So, the amount of use of the application with them decreases day by day.

However, by assessing applications, it is possible to learn how well they work to enhance self-care practices, self-management, self-efficacy, control over a disease, and disease recovery [84‐87]. Patients may utilize an application continually if it is efficient in the dimensions that were presented. Organizations and hospitals may also encourage people to utilize these resources. Patients who make use of these effective tools will reduce the number of people who visit medical facilities physically, preventing overcrowding. Additionally, patients will spend less time traveling to treatment facilities and pay lower treatment costs [17]. On the other hand, studies on app evaluation that publish their findings can assist other app designers and developers in creating the best possible apps. For instance, a city or village’s culture may not support the use of a particular color in the design of an application. When creating their applications, designers are not permitted to use this color. On the other hand, these people can spend less time and money designing and developing an application after seeing the results of these studies. One of the additional benefits of evaluation is that it raises patients’ knowledge and awareness of applications of self-care in the field of health [88‐90]. Patients can then easily learn how to use the applications and become familiar with the various features that a self-care application should have. The evaluation of applications also increases the likelihood that patients will develop loyalty and a sense of community [90]. The patient will feel more accountable for enhancing the application’s quality when he participates in its evaluation and will offer the research team the necessary feedback.

Evaluations may have disadvantages in addition to their benefits. The expenses incurred to motivate individuals to participate in the evaluation process are the first disadvantages of evaluation. For instance, patients typically decline offers of free participation in studies. So, researchers must pay them the required fees to take part in the study. On the other hand, researchers may need to buy tools to record the evaluation process in order to evaluate an application according to the type of evaluation method, such as video cameras, microphones and headsets, audio recording tools, evaluation analysis software, etc. [91]. On the other hand, it takes a lot of time to complete evaluation process. In order to assess an application’s long-term effectiveness, users occasionally need to use it for days and hours. As a result, both the research team and the patients will find it boring.

Sometimes, in some evaluation methods, the evaluation of an application for users does not produce satisfactory and good results [82, 83]. Because of this, users of this application might become discouraged and stop using it altogether. These situations can occasionally arise from a lack of time for an evaluation or from selecting an improper evaluation technique. Therefore, care must be taken in selecting the method and length of the evaluation in accordance with the purpose of the designed application. It should be noted that one of the disadvantages of self-care applications is that they are constantly being evaluated because of updates. These ongoing assessments could be very expensive for designers and the people who develop them.