RESEARCH ARTICLE Open Access
Patient and physician perspectives of a
smartphone application for depression: a
qualitative study
Marie-Camille Patoz1, Diego Hidalgo-Mazzei2, Olivier Blanc1,3, Norma Verdolini2, Isabella Pacchiarotti2,
Andrea Murru2, Laurent Zukerwar4, Eduard Vieta2, Pierre-Michel Llorca1,3 and Ludovic Samalin1,3*
Abstract
Background: Despite an increasing number of smartphone apps, such therapeutic tools have not yet consistently
demonstrated their efficacy and many suffer from low retention rates. To ensure the development of efficient apps
associated with high adherence, we aimed to identify, through a user-centred design approach, patient and
physician expectations of a hypothetical app dedicated to depression.
Methods: We conducted semi-structured interviews with physicians (psychiatrists and general practitioners) and
patients who had experienced a major depressive episode during the last 12 months using the focus group
method. The interviews were audio recorded, transcribed and analysed using qualitative content analysis to define
codes, categories and emergent themes.
Results: A total of 26 physicians and 24 patients were included in the study. The focus groups showed balanced
sex and age distributions. Most participants owned a smartphone (83.3% of patients, 96.1% of physicians) and were
app users (79.2% of patients and 96.1% of physicians).
The qualitative content analysis revealed 3 main themes: content, operating characteristics and barriers to the use
of the app. Expected content included the data collected by the app, aiming to provide information about the
patient, data provided by the app, gathering psychoeducation elements, therapeutic tools and functionalities to
help with the management of daily life and features expected for this tool. The “operating characteristics” theme
gathered aims considered for the app, its potential target users, considered modalities of use and considerations
around its accessibility and security of use. Finally, barriers to the use of the app included concerns about potential
app users, its accessibility, safety, side-effects, utility and functioning. All themes and categories were the same for
patients and physicians.
Conclusions: Physician and patient expectations of a hypothetical smartphone app dedicated to depression are
high and confirmed the important role it could play in depression care. The key points expected by the users for
such a tool are an easy and intuitive use and a personalised content. They are also waiting for an app that gives
information about depression, offers a self-monitoring functionality and helps them in case of emergency.
Keywords: Smartphone, Mobile health, Application, Depression, Major depressive episode
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* Correspondence: lsamalin@chu-clermontferrand.fr
1Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont
Auvergne, EA 7280 Clermont-Ferrand, France
3Fondation FondaMental, Hôpital Albert Chenevier, Pôle de Psychiatrie,
Créteil, France
Full list of author information is available at the end of the article
Patoz et al. BMC Psychiatry           (2021) 21:65 
https://doi.org/10.1186/s12888-021-03064-x
Background
Depression is a common psychiatric disorder with a
prevalence reaching more than 300 million people around
the world [1]. Its impact on patients’ psychosocial func-
tioning and quality of life makes it a leading cause of dis-
ability worldwide [2, 3]. Despite the existence of effective
treatments, such as antidepressants and cognitive-
behavioural therapy, almost half of patients with depres-
sion stay untreated [4]. The appearance of computers and
internet development in the ‘90s brought about the idea
that technological devices could be used as therapeutic
tools [5–8] so as to improve treatment rates [9].
In recent decades, the development of new technologies
and their worldwide spread have led the way to new thera-
peutic and screening tools in mental health [10]. This
field, called “mobile health” or “m-health” [11, 12], has
seen exponential growth with more than 10,000 down-
loadable mental health smartphone applications (apps) as-
sociated with the extensive use of wearables such as
smartbands or smartwatches [13]. Although m-health is a
promising field for increasing access to mental health pro-
grammes, their current use in clinical practice is limited
and most of the available apps have not yet consistently
demonstrated their effectiveness in the management of
depression [14]. Several causes may be considered regard-
ing these two issues. First, most of the apps for depression
fail to incorporate evidence-based practices or clinical ex-
pertise into their design [15–18]. Conversely, most of the
scientifically validated apps are not available in apps stores
[16, 19, 20]. Finally, m-health suffers from a low retention
rate and engagement by users [21, 22] and is rarely inte-
grated into clinical practice, relegating apps to a “self-
medication tools” status [23, 24].
To overcome these issues, it could be of interest to im-
plement a user-centred design approach to develop m-
health tools to remain as close as possible to patient and
physician expectations; this would facilitate both im-
proved retention rates and app implementation in pro-
fessional healthcare practice [21, 23].
Qualitative analysis is commonly used to assess pa-
tients’ expectations in various domains. It has mostly
been used to evaluate patients’ use of pre-existing apps
for depression [25, 26] or to explore the expectations of
an app for depression in young people [27, 28]. To the
best of our knowledge, no qualitative study has investi-
gated both patient and physician expectations of a
smartphone app dedicated to depression including pa-
tients with previous major depressive episodes (MDE),
general practitioners and psychiatrists.
Methods
Study design
The perceptions and expectations of patients, general
practitioners and psychiatrists concerning a hypothetical
smartphone app dedicated to depression were investi-
gated by using a qualitative design with a focus group
methodology. The focus group method has been chosen
because it is a reliable way to assess the participants’ ex-
pectations by facilitating the sharing of ideas and experi-
ences among them.
The focus groups were conducted between November
2018 and May 2019 in France. Patients and physicians
were allocated to separate groups. Psychiatrists and gen-
eral practitioners were distributed randomly in the phy-
sicians groups.
Sample and recruitment
Patients included were adults with a diagnosis of MDE
in the last 12 months according to the Diagnostic and
Statistical Manual of Mental Disorders - 4th edition,
Text Revision (DSM-IV-TR) criteria [29]. They were re-
quired to understand and be fluent in French.
Physicians were psychiatrists or general practitioners
working in the private and/or public sectors and dealing
with patients with MDE in their clinical practice.
Eligible participants (patients and physicians) were
screened by the investigator centres hosted by academic
Departments of Psychiatry (Clermont-Ferrand, Lyon,
Grenoble).
Physicians were solicited by email or by phone to
participate.
Patients were recruited among in- and outpatient ser-
vices of investigator centres. Those who gave consent to
be contacted were followed up to arrange participation.
The focus groups were held in the centre where the par-
ticipants were recruited.
The study was carried out in accordance with ethical
principles for medical research involving humans
(WMA, Declaration of Helsinki). The assessment proto-
col was approved by the relevant ethical review board
(CPP EST I, 2018-A01469–46). All subjects provided
written informed consent to participate.
Data collection
After a literature search on m-health and smartphone
apps for depression, mirrored semi-structured interview
guides have been established for patients and physicians
(Additional file 1).
Before starting the session, patients completed a sur-
vey with their sociodemographic information, including
age, gender and living place (urban or rural). They also
indicated their smartphone and app use habits. Finally,
the severity of their depressive symptoms was measured
using the Inventory of Depressive Symptomatology
(IDS-SR) questionnaire. The IDS-SR is a 30-item self-
rated questionnaire assessing all the criterion symptom
domains designated by the DSM-IV-TR [30].
Patoz et al. BMC Psychiatry           (2021) 21:65 Page 2 of 12
Physicians’ age, gender, type of practice (public or pri-
vate), number of visits per week, number of patients
with depression seen each week and smartphone and
app use habits were assessed through a questionnaire.
Each focus group included 6 to 8 participants and
lasted from 60 to 90min. There was an interviewer and
an observer present for each group (LS, MCP or OB), all
familiar with and well trained in the focus group meth-
odology. All focus groups were audio recorded and tran-
scribed verbatim.
Analysis
Data collection and analysis were conducted at the same
time in accordance with established qualitative methodolo-
gies [31]. After a focus group was transcribed verbatim, it
was fully read then independently and manually coded by
two researchers (LS and MCP). To gain familiarity with the
content, the transcripts were read several times. Each unit of
text was then coded, a code being defined as a meaningful
unit describing a section of text (for example, the code
“Helping patient’s self-evaluation” described the following
text section: “With a self-administered survey on the app, the
patient could do self-assessments”). Codes were organised
into categories (for example: “data provided by the app”, in-
cluding codes such as “exercises” or “therapeutic tools”) and
themes (for example, “content of the app”, including categor-
ies such as “features” or “data collected by the app”). The
codes, categories and themes were compared and agreed
upon among the research team. In the case of discrepancies
between researchers, agreements were reached by individu-
ally clarifying the meaning of a code and discussing its inter-
pretation until mutual consent was achieved. If necessary,
the codes, categories and themes were updated. Team meet-
ings were held to discuss and monitor coding consistency
and to address the analytic validity of the identified themes.
Moreover, the research team met to ensure that the findings
were internally consistent and supported by the data from
the participants’ interviews. After four patient focus groups
and four physician focus groups, no new codes or categories
were emerging, indicating the reaching of data saturation.
Patients and physicians respective focus groups have
been analysed separately to identify the discrepancies be-
tween them. The two codebooks were then merged into
a single codebook.
Sociodemographic data of the sample are presented as
the mean (Standard Deviation, SD) for continuous vari-
ables and frequency distribution for categorical variables.
Results
Participant characteristics
The sample’s general characteristics are summarised in
Table 1. A total of 24 patients and 26 physicians were
included in the study.
For patients, the focus groups showed balanced sex
(male/female ratio = 13/11) and age distributions (from
20 to 73 years). The mean ± SD age was 51.5 (± 15.5).
Most of the patients had a smartphone (83.3%) and were
app users (79.2%).
For physicians, the focus groups also showed balanced
sex (male/female ratio = 13/13), age (from 31 to 67 years)
and type of practice distributions (private/public ratio =
13/13). The mean ± SD age was 45.5 (± 12.2). Most of
the physicians had a smartphone (96.1%) and were app
users (96.1%).
Identification of themes
All data were collected during the focus groups. Within-
group consensus was rare, as the point of qualitative re-
search is to highlight all the opinions and not to find a
consensual one.
A content analysis of the verbatim data resulted in pri-
mary codes, which, after an inductive interpretation and
Table 1 Sample characteristics (n = 50)
Patient characteristics (N = 24) Mean ± SD or n (%)
Male 13 (54.1)
Age 51.5 ± 15.5
Urban living 11 (45.8)
IDS-SR score 36.9 ± 12.2
Phone owners 24 (100.0)
Smartphone owners 20 (83.3)
Android /IOS 18 (75) / 2 (8.3)
App users 19 (79.2)
App number 16.2 ± 19.0
Health App number 0.3 ± 0.6
Physician characteristics (N = 26) Mean ± SD or n (%)
Male 13 (50.0)
Age 45.5 ± 12.2
Urban practice 24 (92.3)
General Practitioners 10 (38.5)
Private practice 13 (50.0)
Years of practice 15.8 ± 11.6
Visits per week 66.8 ± 50.0
Patients with depression seen per week 14.0 ± 11.0
Phone owners 26 (100.0)
Smartphone owners 25 (96.1)
Android/IOS 14 (53.9) / 11 (42.3)
App users 25 (96.1)
App number 28.9 ± 29.0
Health App number 2.8 ± 3.1
SD standard deviation, IDS-SR inventory of depressive symptomatology, IOS
iphone operating system
Patoz et al. BMC Psychiatry           (2021) 21:65 Page 3 of 12
categorisation process, were structured within three
themes (Table 2):
1. Content of the app
2. Operating characteristics
3. Barriers to the use of the app
Theme 1: content of the app
Data collected by the app
Patients and physicians felt that an ideal app should
collect data about its users to ensure the delivery of a suit-
able content. They mentioned the creation of a profile for
the patient using the app, with medical history and general
information, including their interests and leisure activities.
Patients and physicians agreed on the need to assess
symptoms. Opinions diverged on the way to do it, some
considering the use of validated questionnaires and
scales and others showing a preference for free texts or
logbooks. Mood charts were described by patients and
physicians as useful items. It was considered a good
method to collect symptom descriptions, including their
intensity, chronology, rhythm, evolution and their im-
pact on patients’ quality of life. In addition to the collec-
tion of symptoms, both patients and physicians
mentioned the benefits of checking medication uptake,
allowing a close monitoring of medication compliance.
“With a self-administered survey on the app, the pa-
tient could do self-assessments. He could follow his
clinical status and this could help him to realise ‘I
feel better than last week.’” Physician 1, group 3.
Among participants, physicians only discussed the
interest of using passive phone data (data collected with-
out the active action of the patient; i.e. the number of
steps a day…), considered as a desirable feature in order
to collect reliable information on patients’ state without
active participation. They were of the opinion that this
approach would overcome patients’ subjective assess-
ments in order to obtain reliable and accurate data.
Some physicians, however, were sceptical of this intru-
sive process and raised its possible non-acceptance by
patients.
“Collection of passive data. It is the most obvious
interest point. […] If we can get data from SMS and
other messaging apps, we will have, in the end, really
precise clinical indicators. The only comparable
thing would be to discuss with a caregiver living with
the patient 24/7.” Physician 4, group 1.
Data provided by the app
Patients and physicians suggested several tools that help
them in daily life that should be integrated within the
app. They included a diary to keep appointments and a
phonebook to facilitate communication with healthcare
professionals and associations.
Information about depression was also considered,
organised in different sections: a clinical section with
symptom descriptions, a medication section with thera-
peutic strategies, drug interaction and potential side ef-
fects, and a social section to help them with
administrative tasks. The lack of knowledge about the
disease has been pointed out to explain this need for in-
formation about depression. Furthermore, patients and
physicians showed a real expectation of professional ad-
vice in various domains such as therapeutic adaptation
in crisis or alternative medicines.
“I would like to know, considering our usual medica-
tion, if we can take other drugs. Me for example, I
take lithium, and with lithium, you cannot take, for
example, non-steroidal anti-inflammatory drugs. So,
maybe there are other drugs we cannot take?” Pa-
tient 1, group 3.
Patients and physicians also cited several exercises and
therapeutic tools they would like to find in this app such
as games, relaxation sessions or cognitive-behavioural
therapy exercises. They explained that this kind of tool
could be an easy way to extend the work initiated with
the therapist in face-to-face visits. They also agreed on
the necessity of specific content for physicians, including
patient profiles, clinical and therapeutic recommenda-
tions based on clinical practice guidelines and a messa-
ging service. This content could support physicians to
optimise patient care and sustain interactions between
patients and therapists, thus providing feedback regard-
ing patients’ mental states through the use of the app.
“From the psychiatrist side, if I had to have such an
app, I’d like to have therapeutic help finding the
Table 2 Analysis codebook
Theme Categories
Content of the app Data collected by the app
Data provided by the app
Features
Operating characteristics Relevant population
Aims of the app
Modalities and frequency of use
Accessibility and visibility
Security
Barriers to the use of the app Users and accessibility
Safety and side effects
Utility and functioning
Patoz et al. BMC Psychiatry           (2021) 21:65 Page 4 of 12
next line of treatment. The app could use the previ-
ous treatment of the patient and even his medical
history to determine the best medication to use next.”
Physician 4, group 3.
Among participants, only patients asked for other pa-
tients’ testimonies, explaining they could feel comforted
by reading stories from other people struggling with de-
pression. They also expressed a need for a medical chat
room to receive reliable and adapted advice.
Features
Patients and physicians stated that the app should be tai-
lorable. Personalisation was seen as the best way to ob-
tain an app suitable for the greatest number of people
that is able to adapt to patients’ clinical states and their
changes.
Various technical features were suggested, such as
automatic replies by notifications or SMS or through a
virtual interlocutor (i.e. chat bot). Patients and physi-
cians considered that the app could also use and collect
data provided by other connected tools (e.g. wearables)
to improve its capacity to assess patients’ symptoms in
momentary ecological conditions.
Charts were described as being useful to display symp-
toms collected by the app. The use of different colours
and smileys was also cited as a smart method of
highlighting important information and giving the app a
friendly aspect.
“A diagram or a histogram, well visible, easy to read.
We need something more ludic, intuitive and easy.”
Physician 1, group 2.
Dealing with emergencies was a feature judged to be
essential to an app dedicated to depression by both pa-
tients and physicians. Different features were considered
for this purpose, from written advice provided by the
app to a call to their physician or family. Patients and
physicians agreed on the utility of a partnership with
emergency services to ensure a quick and reliable reac-
tion to a suicidal crisis.
“The app could send automatic replies in [the] case
of symptoms worsening. It could be advice or sugges-
tions. In [the] case of suicidal thoughts or immediate
risk, the app could directly call the patient’s phys-
ician.” Physician 6, group 1.
However, physicians expressed some concerns about
emergency management by the app, as developed in the
“security section”. These concerns were not found in the
patients’ groups.
Theme 2: operating characteristics of the app
Relevant population
Participants were invited to discuss an app dedicated to
patients with depression; nonetheless, they emphasised
the need for a tool dedicated to non-diagnosed patients.
To facilitate and increase mental healthcare access, they
suggested an app to screen, among the general popula-
tion, people with a feeling of unease.
“‘ …Do I feel good?’ I think it could be interesting to
help people to ask themselves this question before
seeing a professional. Actually, patients know noth-
ing about depression. They think: ‘I’m just tired, I’m
gonna rest and everything will be alright,’ and [a]
depression diagnosis is made really late. […] Today
people struggle with depression until they are
exhausted. They don’t have the opportunity to assess
themselves. They don’t find an app to know if they
suffer from depression.” Physician 3, group 2.
Patients and physicians also agreed on the necessity of
an app, or a section of the app, dedicated to patients’
caregivers, seen as an essential actor in depression care.
They pointed out caregivers’ usual lack of knowledge
about depression and suggested that an app with infor-
mation about depression and an indication of what they
should do in the case of relapses could be useful.
Regarding the target users of an app dedicated to de-
pression, patients and physicians pointed out the risk of
difficulties in its implementation and use with patients
suffering from severe depression. They considered that it
should be preferable for patients suffering from mild to
moderate depression.
Finally, patients and physicians cited psychiatrists and
general practitioners among healthcare professionals who
could be connected and linked to patients’ accounts.
Aims of the app
Patients and physicians suggested the app could have
different aims. These aims vary according to the targeted
users and their clinical state.
The four main objectives were screening, orientation,
information and monitoring. Screening and orientation
were associated with apps dedicated to the general
population, which could diagnose depression and refer
patients to a mental healthcare professional. Information
was considered in two ways: first, to sensitise the general
population to depression and to destigmatise it; sec-
ondly, within a psychoeducational perspective, for pa-
tients suffering from depression. Monitoring was
considered to overcome the memory bias encountered
in monthly follow-ups, with patients often remembering
how they felt for the few days preceding the visit or
Patoz et al. BMC Psychiatry           (2021) 21:65 Page 5 of 12
focusing on the worst state they have encountered in
that month, regardless of how long it had lasted.
“Sometimes in visits you’re asked, ‘How are you
doing? What happened since the last time?’ And you
have forgot! A useful thing could be a questionnaire
to check your mental state and feelings everyday so
you can show it to your physician on the next visit.”
Patient 5, group 3.
The app was also considered by patients and physi-
cians to be a reassurance tool, providing a presence dur-
ing weekends and physicians’ vacation time.
Physicians suggested other objectives not mentioned
by patients. They considered the app to be of additional
value in depression care, being an intermediate between
them and their patients, allowing access to complemen-
tary information and facilitating the discussion of per-
sonal topics in visits, such as sexuality. It was also
described as possibly promoting care adherence and re-
ducing anxiolytic use through therapeutic education.
On the other hand, they only insisted on the creation
of a social network allowed by the app, proposing a
forum and chat feature for patients to share their experi-
ences with their peers.
Modalities and frequency of use
Opinions on the modalities and frequency of app use were
numerous and strongly diverged among participants.
The optimal frequency of use ranged from daily to bi-
weekly or only on the patient’s request. Where some patients
or physicians considered unlimited use of the app, others
preferred to restrict its use to depressive episodes only.
“I think this app should have [an] unlimited lifetime;
it shouldn’t stop. Even if it means we have to deacti-
vate some features with time…” Physician 2, group 4.
Only physicians discussed the possibility of naming a
trusted person among the patient’s entourage whose
contact information (phone or email) would be regis-
tered in the app. The trusted person could be contacted
(i.e. an alert by mail or SMS) by the app in case of an
emergency or a reminder with their phone number
could be displayed to make it easier for the patient to
call them when they are feeling unwell. They also sug-
gested the reception of patient data should occur during
working hours only. Some even suggested data should
only be shared during patient visits and that physicians
should only be contacted through the app in the case of
an emergency. To facilitate the use of the app and help
them to gain time, data transfers to physicians’ medical
software were also considered.
“When I see the patient in visit[s], I could log on the
patient’s app. I could even transfer what has been
measured by the app on my medical software.” Phys-
ician 5, group 1.
Conversely, patients insisted on the need to be able to
reach their physicians, or at least a mental healthcare
professional each time they needed to, regardless of the
time or day.
Accessibility and communication around the app
Both patients and physicians felt that access to the app
should be easy. They suggested it could benefit from
good visibility on the web and be presented to patients
through educational material available in physicians’
waiting rooms.
“So, when you write ‘Am I depressive?’ on an internet
search engine, the first result should be this app, and
you just have to click on it to download it.” Physician
1, group 2.
Access to the app was a dividing point, with partici-
pants in favour of unrestricted access in app stores and
others suggesting an app available after medical pre-
scription only.
Patients and physicians emphasised the need for a free
app to ensure access for all patients with depression, re-
gardless of their incomes.
Security
The app’s data security and privacy policies were dis-
cussed as being a fundamental requirement in both pa-
tient and physician groups. They agreed on access
protected by a password or code. Data storage was a
point of concern; participants considered that such a de-
vice requires dedicated secured servers to store and pro-
tect collected data.
“It’s problematic, we need storage [on a] secured ser-
ver.” Physician 2, group 4.
As mentioned in the “features” section, physicians but
not patients considered an app that would work on pa-
tients’ phones only, with no professional dashboard, as-
suring strict confidentiality and limited access to data.
Physicians also insisted on medico-legal issues raised
by mental health information transmission and emer-
gency management. They emphasised the need for well-
defined conditions of data transmission to physicians,
keeping in mind that they would not check the app dur-
ing nights or weekends and so there may be delays in
emergency situations.
Patoz et al. BMC Psychiatry           (2021) 21:65 Page 6 of 12
“The app could raise some medicolegal issues. If the
patient tries to contact us, it's the same with e-mail,
patients could believe or think we have received and
processed his message. If we don’t receive it, or [we
receive it] too late, we could [be] held medically re-
sponsible.” Physician 4, group 4.
Theme 3: barriers to the use of the app
Users and accessibility
Patients and physicians showed themselves to be scep-
tical about the ability of a patient to use the app during
a depressive episode, regardless of severity. They insisted
on the potential impact of depressive symptoms on the
use of the app, such as cognitive dysfunction and
anhedonia.
Costs and material access were pointed out as limita-
tions of the democratisation of the app, making it a tool
restricted to a privileged population. Patients and physi-
cians also suggested that this kind of device could not be
applied to all age groups, with the risk that older pa-
tients may struggle with the use of new technologies.
Only physicians described the risk of time consump-
tion associated with the use of the app as a strong limi-
tation. They worried about not being able to deal with
the app in addition to their other professional duties.
They also expressed doubts about their ability to inte-
grate these tools into their daily practice.
“Let’s take email: I read it once every two days. I
cannot check it more often. I come back home really
late, 11.30 pm sometimes. Checking mail and SMS
and answering it takes a lot of time. Honestly, I don’t
think I could answer patients contacting me through
an app.” Physician 2, group 3.
Safety and side-effects
Patients and physicians worried about potential side ef-
fects related to the use of the app. Anxiety was seen as a
symptom that could be worsened or created by the app.
Overuse of the app and social withdrawal were also sug-
gested to be potential side effects. Participants assumed
that the daily use of an app would keep users away from
their relatives and so increase withdrawal symptoms
already seen in depressive disorders.
The risk of a decrease in visit frequency with health-
care professionals was suggested, as well as a progressive
replacement of the physicians by the app, both in evalu-
ation and therapeutic aspects. Patients and physicians ar-
gued that the app could provide the therapist with a
feeling of security and encourage them to space appoint-
ments out. They were particularly concerned about the
risk of reducing the number of face-to-face visits, mean-
ing for them a loss of human contact, considered as es-
sential in depression care.
“Then I think we should be careful with these med-
ical apps because in the end it will promote tele-
medicine: if all indicators are positive, the patient
takes its treatments, he displays happy smileys, why
[should we see] him in visits?” Physician 1, group 4.
Utility and functioning
Among participants, some patients and physicians
showed themselves to be sceptical about the utility of
such an app. They expressed that they could not see any
utility in it, thinking that the use of a connected device
for psychotherapy is nonsense. They also emphasised
the already wide range of apps available for depression
and explained a new app would not improve care for pa-
tients with MDE.
Some physicians suggested that psychosocial interven-
tions such as psychoeducation could not be done without
healthcare professionals and expressed doubts about pa-
tients’ comprehension of information delivered by the app.
“The issue is [the] interpretation of messages received
by the patient. You don’t have an instantaneous
feedback for it and if he had a wrong interpretation
it will not help him.” Physician 3, group 2.
“I think that psychiatry is based on discussion, trust,
empathy, everything that makes medicine an art,
and I think all this cannot pass through an app.”
Physician 2, group 2.
Only patients expressed doubts about the potential
marketing use of the app, and stated that advertisements
would be unwelcome while using the app and would
make them uncomfortable.
Discussion
This qualitative study is the first to assess both physician
and patient expectations of an app dedicated to depres-
sion. The use of the focus group method provided a
range of experiences and opinions among the partici-
pants and a relationship of trust among the group. The
discussions it allows increased the role of the partici-
pants who collectively built the results of the research.
All themes and categories were the same for patients
and physicians, highlighting a shared interest and mutual
needs regarding this tool. However, some code differ-
ences pointed out the potential conflict between pa-
tients’ needs and physicians’ constraints. Direct access to
a professional through the app, which was a strong wish
expressed in the patient group, was not mentioned in
the physician group and echoed the worry about physi-
cians’ availability to use an app. Nevertheless, these con-
flicts remained scarce and this study revealed strong
similarities between patient and physician expectations,
Patoz et al. BMC Psychiatry           (2021) 21:65 Page 7 of 12
revealing that an app suitable for both patients and phy-
sicians could easily be developed. Patients and physicians
expressed expectations regarding its content, its operat-
ing characteristics and discussed potential barriers to its
implementation in real-world clinical practice. Content
considered by participants included data provided to and
delivered by the app, as well as features thought to be
useful for that kind of tool. Data collection methods
must gather information about the patient using the app
to evaluate their mental state and to inform physicians
of the evolution of depressive symptoms. Data delivered
by the app should provide psychoeducation elements,
therapeutic tools and various functionalities to aid the
management of daily life. Features considered for the
app were meant to facilitate its use by physicians and en-
sure patient care in the case of an emergency. The “op-
erating characteristics” theme showed strong
heterogeneity between participants’ expectations regard-
ing target users, frequency of use and aims of the app.
This heterogeneity emphasised the interest of a tailor-
able tool to meet all the needs and desires of patients
and physicians. Finally, this study highlighted doubts
and limitations that both patients and physicians may
have regarding an app dedicated to depression. These
barriers included concerns about users of the app, its ac-
cessibility, safety, side effects, utility and functioning.
Most of our results are consistent with previous quali-
tative studies on health apps, whether they focus on apps
for depression or not. Regarding content, information on
the disorder and day-to-day life-supporting activities like
music, breathing exercises and videos are often cited as
expected items [27, 32, 33]. Self-tracking is a highly
rated activity of health apps [27, 32] and is described by
patients as a reason to return to the app [34]. Similarly
to our findings, among possible app features, personal-
isation is the most requested and liked, both by patients
and professionals [26, 27, 32–35]. The expected aims of
such apps found in the literature included psychoeduca-
tion [35], monitoring [27, 32, 35], providing a presence
between face-to-face visits [27] and social connectivity
[26, 32]. Consistently with our result, other studies
highlighted two main barriers to the use of apps cited by
physicians: lack of time and medicolegal responsibility
[27, 28]. Financial aspects and deficiency in technological
competencies are common barriers to the use of apps
for patients [26, 33, 35].
An important issue considered by the participants in
our study was the type of population that could benefit
from an app dedicated to depression. First, in line with
other studies, patients and physicians agreed to focus on
an app for people suffering from mild-to-moderate de-
pression [24]. This statement tended to be confirmed by
a recent meta-analysis focusing on the efficacy of app in-
terventions for depressive symptoms, the post hoc
subgroup analysis showing that significant benefits from
smartphone apps were only found for patients with self-
reported mild-to-moderate depression [36]. Those re-
sults should be considered carefully, with the variations
in subgroup sample sizes leaving the analyses for major
depression underpowered to detect significant effects.
Moreover, a more recent study identified that more se-
vere depression led to enhanced information seeking,
counteracting the theory that severe depression keeps
patients from using apps [37].
An app to screen potential depression in the general
population was also discussed. Participants emphasised
the significant role that this app could provide in facili-
tating access to mental health for depressed people.
They assumed that the large-scale use of such an app
could decrease the mean duration of untreated depres-
sion and hence the recurrences and the duration of
MDEs [38, 39]. In line with our results, several studies
pointed out the possible interest of apps for depression
screening in the general population, showing that a large
number of people from different countries were search-
ing for, and willing to use, that kind of tool [40]. Add-
itionally, several apps using text analysis have shown
their ability to improve the immediate detection of de-
pressive symptoms [41, 42]. Finally, several studies
highlighted the fact that depression screening apps could
motivate some users to discuss the obtained results of
the tests with healthcare professionals for further diag-
nosis and management [43, 44].
Our findings also emphasised the interest in an app
that would not be time-consuming for physicians and
could help treatment decision-making in patients with
depression based on the most updated and high-quality
evidence. To the best of our knowledge, there are very
few apps currently available providing evidence-based
guidance for treatment decision-making to physicians.
One study highlighted that an app could be an effect-
ive tool for both increasing confidence in depression
treatment and educating physicians [45], pointing out
the interest to develop more connected tools for health-
care professionals.
Finally, participants mentioned the usefulness of an
app for informal caregivers, to inform them, help them
in supporting their ill relative and to destigmatise mental
health. This demand is supported by the results of a re-
cent systematic review focusing on apps dedicated to
caregivers, showing most of the included studies proved
their effectiveness in the overall well-being of the care-
givers [46]. Apps dedicated to caregivers, who are often
suffering themselves from depression or anxiety, could
significantly improve mental healthcare regarding their
essential role for patients suffering from depression [47].
These findings highlight that a single app is not
enough: multiple versions of the app are needed to
Patoz et al. BMC Psychiatry           (2021) 21:65 Page 8 of 12
encompass the support and care objectives of patients,
mental health professionals and informal caregivers.
One crucial feature expected by participants was self-
monitoring. The main interest of it is to improve mental
health and wellbeing by increasing emotional self-
awareness [48, 49]. The use of apps for self-monitoring
allows precise, easy and quick ecological momentary as-
sessment with the possibility of providing real time feed-
back for patients and alerts for clinicians in case of
emergencies. It would also allow clinicians to monitor
the efficacy of treatment over time, predict short-term
mood changes and detect the worsening of symptoms
early on [50]. There are many apps for depression inte-
grating a self-monitoring feature and several studies have
examined their usability, acceptability, adherence and ef-
fectiveness. Self-monitoring of depressive symptoms on
patients’ phones has been shown to be easy and reliable
[51, 52] and several studies highlighted its effectiveness
to improve depressive symptoms [36, 53, 54]. A study on
untreated patients with symptoms of depression and
anxiety also showed that access to daily self-monitoring
helped them to translate their intention to seek treat-
ment into actual treatment-seeking behaviour [55]. Even
if this effect was small, it defines self-monitoring as a
promising tool to decrease the number of untreated pa-
tients suffering from depression. However, the main
bottleneck of self-monitoring is the low retention rate of
apps offering this feature. For this particular point, stud-
ies showed inconsistent results, where some highlighted
a quick drop out rate of self-monitoring apps [56, 57],
while others noted, conversely, a fairly high retention
rate for these tools [52, 54, 58].
In addition to self-monitoring and patients’ active in-
put of data, passive data collection has been suggested
by physicians in our study. This is consistent with the
new research allowed by advanced technologies such as
digital phenotyping [59], aiming to determine clinical
phenotypes by measuring patient behaviours from
smartphone sensors [60]. Requiring no active participa-
tion from the patient, the collection of passive data has
been increasingly studied in recent years and seems to
be a promising field for the future of m-health. This
method could indeed allow ecological momentary as-
sessment of several parameters and could be a strong
tool to improve depression care. An interesting applica-
tion domain for this method is the use of an algorithm
to facilitate the detection of new MDEs that could be of
significant help for clinicians in the follow up of patients
with mood disorders [61–64]. A study focusing on thera-
pists’ ability to detect negative changes in their patients
showed that clinical judgement allowed the detection of
only 21% of symptom worsenings [65]. Early detection
of an episode with passive data collection could then fa-
cilitate the quick reaction of physicians and improve
patients’ outcomes [66]. Despite being promising, passive
data collection is, as shown in our study, not yet ac-
cepted by everyone, whether patients or physicians, and
remains a strong barrier to the use of apps.
The analysis of the barriers identified the potential re-
placement of the physician by the app as a major con-
cern in psychiatry, where state-of-the-art methods
require human interaction. This barrier is raised in sev-
eral studies who mentioned the lack of therapist contact
as a negative point of apps [24, 34, 67]. This issue could
be overcome with the use of mixed methods or adjunct-
ive apps, integrating the app in face-to-face therapy. This
kind of approach has shown better efficacy than self-
guidance therapy only through web intervention or
smartphone apps [68–71], thus demonstrating the essen-
tial role of the therapist in patient care. All these ele-
ments emphasised an essential point: complementarity
between therapists and m-health tools. In Western
countries, the main aim of these devices is to support
existing care by providing, for example, better informa-
tion regarding the patient’s daily state through moment-
ary ecological assessment. The use of new technologies
should not be seen as a replacement tool for physicians
but as an opportunity to increase the quality of care pro-
vided. The inclusion of apps in therapy could then be
compared to the development of imagery devices in
radiology, improving diagnosis without removing the
need for clinical examination and physicians’ knowledge
and expertise.
Perspectives
The key findings of this study allow us to build a list of
suggestions for app developers in the field of depression
to fill both patients’ and physicians’ expectations:
– The use of the app should be easy and intuitive.
– The app should be personalised. The content and
functioning of the app should be tailored to each
patient and should adapt to the patient’s condition
over time.
– A self-monitoring function should be included to
both increase the patient’s self-awareness and
sharpen the evaluation of the physician. This func-
tion should focus on key symptoms and offer the pa-
tient and the physician the possibility of choosing
other symptoms to monitor.
– The app should be able to deal with emergency
situations. At the least, it should include a tailorable
crisis procedure and, at best, include a partnership
with the local emergency service.
– The app should provide the patient with
information about depression and/or
psychoeducational messages.
Patoz et al. BMC Psychiatry           (2021) 21:65 Page 9 of 12
Furthermore, our results highlighted several key points
that should remove the potential barriers to the use of
the app:
– Relevant users should be precisely targeted to ensure
their capacities to use the app, with particular
attention given to the intensity of depression.
– To reduce the potential difficulties bound to the use
of the app, physicians should plan a dedicated
educational time with the patient to explain the
functioning of the app. A user guide should also be
included and delivered to the patient.
– Mixed approaches should be preferred. The app
should be fully integrated with the usual therapy and
be an adjunctive tool rather than an independent
one. The use of the app should not lead to any
reduction of the frequency of visits to the therapist.
– The use of the app should be free of charge.
– Access should be protected by a password and data
stored in a secured server.
Strengths and limitations
This study has a number of limitations. Selection bias
may have occurred: patients’ recruitment was limited to
France for practical reasons. Furthermore, most of the
physicians practiced in urban areas. Therefore, the find-
ings may not be transferable to practitioners in rural
areas. This study was also limited to some degree in the
use of focus groups as a methodology: group dynamics
might have, in some way, shaped the expectations
expressed by participants and the interviewers’ personal
skills and attributes could also have influenced the na-
ture and quality of the gathered data. However, the use
of focus group is also one of the strengths of this study
as it allows for interaction among participants and facili-
tates discussion and sharing of ideas.
Conclusion
Physician and patient expectations of a smartphone app
dedicated to depression are significant, suggesting a real
place for such a device in the management of depres-
sion. The key points expected by the users for such a
tool are an easy and intuitive use and a personalised
content. They are also waiting for an app that gives in-
formation about depression, offers a self-monitoring
functionality and help them in case of emergency. To
ensure good implementation and retention rates, these
expectations must be of major concern while developing
these tools. Finally, apps should be considered as med-
ical devices and be tested in clinical trials. Consequently,
their development requires further studies to ensure
their efficacy and safety.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12888-021-03064-x.
Additional file 1. Interview guide. Details of the interview guide used
to facilitate discussion within the focus groups.
Abbreviations
MDE: Major depressive episode; FG: Focus group; DSM-IV-TR: Diagnostic and
statistical manual of mental disorders - 4th edition, text revision; IDS-
SR: Inventory of depressive symptomatology; SD: Standard deviation;
CBT: Cognitive-behavioural therapy
Acknowledgements
We thank all the physicians and patients who participated in the study. We
would also like to acknowledge Maryline Chalmeton for providing support
on the study.
Authors’ contributions
MCP, OB, PML and LS were involved in the study conceptualisation and
design. Analyses and interpretation of the data were carried out by all the
authors (MCP, DHM, OB, NV, IP, AM, LZ,EV, PML and LS). The first draft of the
manuscript was written by MCP and LS. All authors (MCP, DHM, OB, NV, IP,
AM, LZ, EV, PML and LS) contributed to and approved the final manuscript.
Funding
This work was supported with funding from the Auvergne-Rhône-Alpes Re-
gional Health Agency and the Clermont-Ferrand University Hospital Center
in France.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Ethics approval and consent to participate
The study was carried out in accordance with ethical principles for medical
research involving humans (WMA, Declaration of Helsinki). The assessment
protocol was approved by the relevant ethical review board (CPP EST I,
2018-A01469–46). All subjects provided written informed consent to
participate.
Consent for publication
Not applicable.
Competing interests
Dr. Pacchiarotti has received CME-related honoraria, or consulting fees from
ADAMED, Janssen-Cilag and Lundbeck.
Dr. Murru has served as a consultant, adviser or speaker for Adamed,
AstraZeneca, Bristol-Myers Squibb, Janssen-Cilag, Lundbeck, Otsuka and
Sanofi-Aventis and has received a grant (PI19/00672) from the Instituto de
Salud Carlos IIISubdirección General de Evaluación y Fomento de la investi-
gación, Plan Nacional 2019–2022.
Prof. Vieta has received grants and served as a consultant, advisor or CME
speaker for the following entities: AB-Biotics, Abbott, Allergan, Angelini, Astra-
Zeneca, Bristol-Myers Squibb, Dainippon Sumitomo Pharma, Farmindustria,
Ferrer, Forest Research Institute, Gedeon Richter, Glaxo-Smith-Kline, Janssen,
Lundbeck, Otsuka, Pfizer, Roche, SAGE, Sanofi-Aventis, Servier, Shire, Suno-
vion, Takeda, the Brain and Behaviour Foundation, the Spanish Ministry of
Science and Innovation (CIBERSAM), the EU Horizon 2020 and the Stanley
Medical Research Institute.
Prof. Llorca has received grants, honoraria or consulting fees from ESAI,
Gedeon Richeter, Janssen, Lundbeck, Otsuka and Sanofi.
Dr. Samalin has received grants, honoraria or consulting fees from
AstraZeneca, Bristol-Myers Squibb, Janssen-Cilag, Lundbeck, Otsuka, Sanofi-
Aventis, and Takeda.
The other authors declare that they have no conflicts of interest.
Author details
1Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont
Auvergne, EA 7280 Clermont-Ferrand, France. 2Bipolar and Depressive
Patoz et al. BMC Psychiatry           (2021) 21:65 Page 10 of 12
Disorders Unit, Hospital Clinic, University of Barcelona, Institute of
Neuroscience, IDIBAPS, CIBERSAM, 170 Villarroel st, 12-0, 08036 Barcelona,
Catalonia, Spain. 3Fondation FondaMental, Hôpital Albert Chenevier, Pôle de
Psychiatrie, Créteil, France. 4Clinique Mon Repos, Ecully, France.
Received: 20 October 2020 Accepted: 14 January 2021
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