SummaryAs an adjunct to face-to-face counseling, individuals with depression and/or other mood disorders log and track their daily moods using a mobile phone application. Known as Mood 24/7, the application sends a daily text message that prompts an assessment and reporting of mood on a scale of 1 to 10. It also allows patients to annotate the rating with explanatory notes and to share a secure, Web-based personal mood chart with providers, who use this information to inform treatment decisions. The program has led to much higher patient adherence to daily mood tracking (as compared to paper-based tools), better treatment decisions, and positive feedback from both clinicians and patients.Suggestive: The evidence consists of comparisons of patient adherence to daily mood tracking with Mood 24/7 and paper-based tools, along with survey results and anecdotal feedback from clinicians and patients.
Developing OrganizationsHealthCentral; Johns Hopkins Hospital
Date First Implemented2009
Problem AddressedPatients being treated for mood disorders, borderline personality disorder, and other mental health conditions often find it helpful to track their mood over time, yet few patients have access to tools that help them do so consistently.
- Limited ability to track moods reliably: Emotional self-awareness is an important skill for people with mood disorders and other psychiatric conditions; by recognizing their emotions and emotional patterns, these individuals learn to identify trigger situations, modulate their reactions, and improve coping skills.1 To cultivate emotional self-awareness in their patients, mental health providers often ask them to recall their mood over the past week(s) or month(s); yet most people—particularly those with depression or anxiety—cannot do so accurately.2
- Unrealized potential of mobile applications: Paper-based mood logs and charts can be cumbersome, and as a result only about 10 percent of patients consistently use them to track their mood.2 Mobile phone applications allow patients to easily and reliably track their moods electronically, but very few patients currently have access to such tools.
Description of the Innovative ActivityAs an adjunct to face-to-face counseling, individuals with depression and/or other mood disorders log and track their daily moods using a mobile phone application. Known as Mood 24/7, the application sends a daily text message that prompts an assessment and reporting of mood. It also allows patients to annotate the rating with explanatory notes and to share a secure, Web-based personal mood chart with providers, who use this information to inform treatment decisions and observe the effects of treatment over time. Key program elements include the following:
- Identification and registration of eligible patients: During office visits, mental health providers identify patients who have difficulty regulating their mood. They describe the Mood 24/7 application to them, including how it can track moods and inform treatment decisions. The provider helps those interested in using the application to register on a secure Web site and select a time to receive the daily text message (see bullet below). Providers may ask patients to sign a consent form that allows different individuals involved in the patient’s treatment to access the information, including psychiatrists, psychologists, therapists, nurses, nurse practitioners, case managers, researchers, or medical assistants.
- Daily text message prompting mood assessment: Each day, the patient receives a text at the designated time that prompts an assessment of average mood over the past 24 hours, rating it on a scale of 1 (low) to 10 (high). Patients can also choose to annotate the numerical assessment; annotations might include information about specific daily events, outcomes of assigned mental health exercises, sleep patterns, medication changes, or other mood-related information. Patients may also add annotations based on a provider’s request for specific mood- or treatment-related information.
- Tracking via mood chart: The patient’s daily responses are added to a Web-based personal mood chart that can be shared with providers, friends, and family. Providers can also add notes to the patient’s record.
- Use during counseling sessions to assist with treatment decisions: During face-to-face counseling sessions, the mental health provider can log onto the secure Web site to review the patient’s data on mood patterns. The patient can also view the data, enabling him/her to understand the mood patterns more accurately and objectively than through memory. The provider can use this information to point out patterns in mood changes, with the goal of improving stress management and coping skills. The provider can also use the mood chart data (along with other relevant information) when making treatment-related suggestions or adjustments.
- Provider review and annotation at any time: The provider may log in routinely to check on all patients, review data just prior to an office visit, review a patient’s data between visits (e.g., in response to a patient's phone call), or check on a patient’s mood based on a particular concern (such as the patient not showing up for a scheduled visit).
Context of the InnovationThe Johns Hopkins Hospital, an urban academic institution located in East Baltimore, is a 1,015-bed tertiary care facility that treats roughly 268,000 inpatients annually, including patients from across the United States and 126 countries. Four County Mental Health Center, Inc. is a private nonprofit community mental health center providing comprehensive services for people residing in the southeast Kansas counties of Chautauqua, Elk, Montgomery, and Wilson.
The impetus for this program came from Dr. Adam Kaplin, a psychiatrist at the Johns Hopkins Hospital, who noted the dearth of technologies to assist psychiatrists and other mental health clinicians in monitoring patients' moods. Recognizing that his medical colleagues routinely gathered pertinent health information from technologies such as home glucometers and pulse oximeters, he approached product developers at HealthCentral, a health media company headquartered in Arlington, VA, about development of a similar tool to measure patients' moods on a daily basis. Dr. April Foreman, a psychologist with Four County Mental Health Center (the only psychologist in a four-county area in rural Kansas) became one of the earliest community-based adopters of the tool. She thought it would be helpful with her many patients with personality disorders and other mental health conditions associated with significant impairment in emotion regulation.
ResultsThe program has led to much higher patient adherence to daily mood tracking (as compared to paper-based tools), better treatment decisions, and positive feedback from both clinicians and patients.
Suggestive: The evidence consists of comparisons of patient adherence to daily mood tracking with Mood 24/7 and paper-based tools, along with survey results and anecdotal feedback from clinicians and patients.
- High adherence rate: In studies of several populations, approximately 90 percent of Mood 24/7 users regularly assessed and reported their daily mood, well above the 10-percent average adherence rate in those using paper-based tools.
- Better treatment decisions: Anecdotal reports from providers suggest that the system has led to better treatment decisions. For example, after noting a dangerous dip in a patient's mood during a postvisit chart review, one provider decided to check on the patient by phone. He ended up arranging an inpatient admission, which both the patient and provider believe saved her life (since the patient was suicidal). In another example, a provider reduced use of a medication based on the mood chart, which clearly showed that past changes had not negatively affected the patient's mood. The chart allowed the provider to present "objective" patient-reported data, thus making the patient less resistant to the idea of reducing reliance on the medication.
- Positive feedback from clinicians: In surveys, providers clearly prefer Mood 24/7 to traditional paper-based reporting systems, as outlined below:
- Easier to use: Mood 24/7 scored a 4.73 on ease of use (on a 5-point Likert scale, with "5" meaning "strongly agree" and "1" meaning "strongly disagree"), well above the 2.0 average rating for paper-based systems).
- Better tracking: Mood 24/7 scored 4.64 with respect to ability to improve tracking of patients' depression, compared to 1.82 for paper-based systems.
- More useful during visits: Mood 24/7 scored 4.45 with respect to usefulness during patient visits, well above the 1.73 score for paper-based systems.
- Positive feedback from patients: Patients give the program positive ratings, as indicated by the following sample survey responses:
- “It’s like a friend I can count on to call every evening always at the same time, waiting to hear how I’m feeling . . . I began to be able to see my own patterns and associate what was causing ups or downs.”
- “It makes me think about the little things that I stress about sometimes. When I get the text from Mood 24/7, I sit back and think about what is most important to me, and that is being happy.”
- Future study of impact on adherence and keeping appointments: A future study will evaluate the system's impact on medication adherence (filling prescriptions) and keeping provider appointments.
Planning and Development ProcessSelected steps included the following:
- Formalizing relationships: Johns Hopkins representatives and HealthCentral consultants outlined the details of their relationship, in which Johns Hopkins would license the technology to HealthCentral, HealthCentral would develop the product, and Johns Hopkins clinicians and researchers would offer advice and consultation on clinical issues during the development phase.
- Developing the application: HealthCentral employees developed a prototype of the application with input from Johns Hopkins clinicians; the prototype was refined until both HealthCentral and Johns Hopkins were satisfied that the application was ready for a pilot test.
- Pilot testing and revising application: Clinicians in Johns Hopkins Hospital's psychiatry department pilot tested the application for a year. Based on feedback from those involved in the testing, HealthCentral made the system more user-friendly and enhanced its data-tracking capabilities. Revisions continue on an ongoing basis based on clinician feedback.
- Advertising program: HealthCentral promoted the application through its Web site. Dr. Kaplin also identified potential users in community settings, including Dr. Foreman.
- Obtaining patent: Johns Hopkins Hospital has applied for a patent relating to the idea of using mobile phone technology to track moods.
Resources Used and Skills Needed
- Staffing: Adopting the tool within a practice requires no new staff, as existing staff incorporate it into their daily routines.
- Costs: Development costs cannot be shared. Currently, the tool can be used at no cost to providers or patients. Users must have a cell phone with text messaging capability. Safelink, a government-sponsored program, offers free cell phones and texting services for income-eligible individuals in most states. (See the Tools and Other Resources section for more details.)
Funding SourcesJohns Hopkins Hospital; HealthCentral
Tools and Other ResourcesThe Mood 24/7 tool is available free of charge at: http://www.mood247.com/. Information on Safelink is available at: http://www.safelinkwireless.com/Safelink/.
Getting Started with This Innovation
- Reference existing applications to build provider support: Mental health providers may be anxious about adopting mobile technologies. In response to such concerns, would-be adopters can point out that health-related applications for mobile phones have been used successfully to assist patients with many health-related issues, including (but not limited to) diet, exercise, and diabetes control.
- Have users test device: Testing in real-world settings provides valuable feedback that cannot be obtained through laboratory testing.
- Obtain informed consent: Patients must clearly be told who will have access to their information, that information may be printed and placed in their medical record, and that information may not be covered under Health Insurance Portability and Accountability Act privacy regulations. These conversations and a signed consent form should be documented in the medical record.
- Help patients set up and use system: To increase patient comfort, providers may want to help patients register for and use the service for the first time during an office visit.
- Clarify that patients still need a crisis plan: Emphasize to patients that information provided through the system may not be monitored regularly by providers, and hence they still need a crisis plan that allows them to access help immediately if needed.
Sustaining This Innovation
- Review chart with patient in the office: Patients will continue using the tool if they see that clinicians are interested in and use the information during office visits.
- Use trends as prompts during counseling sessions: Viewing mood patterns as a function of time, social context, and other variables helps patients develop insights about their emotional patterns and coping strategies based on these insights. This trend analysis reinforces continued self-monitoring and can motivate behavior change over time.
- Continually refine application: Continually refine the application to reflect how patients and providers use it.
- Ensuring continued funding: Ensure that project developers are committed to continued project funding, especially if the application is to be offered free of charge.
Contact the InnovatorAdam Kaplin, MD, PhD
Assistant Professor of Psychiatry and Neurology
The Johns Hopkins Hospital
600 N. Wolfe St., Meyer 121
Baltimore, MD 21287
Phone: (410) 955-6111
Innovator DisclosuresDr. Kaplin has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesMore information about Mood 24/7 is available at: http://www.mood247.com/.
Mobile tracking used to help patients improve mental health. Behavioral Healthcare. May 27, 2011. Available at: http://www.behavioral.net/news-item/mobile-tracking-used-help-patients-improve-mental-health
The working manuscript for an article about this innovation is available at: http://www.docforeman.com/archives/244
Morris ME, Kathawala Q, Leen TK, et al. Mobile therapy: case study evaluations of a cell phone application for emotional self-awareness. J Med Internet Res. 2010;12(2):e10. [PubMed]
Available at: http://www.jmir.org/2010/2/e10/
2 Interview with Dr. Adam Kaplin, July 19, 2011.
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Original publication: February 01, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: January 28, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.