There has been increasing interest in the use of digital interventions and apps to provide mental health support, particularly given the COVID-19 pandemic and corresponding heightened need for mental health support, as well as limited availability of in-person therapeutic services. The use of mental health apps has the potential to increase access to care in a cost-effective and scalable way.

Despite the enthusiasm around, and proliferation of, mental health apps, a recent systematic review and meta-analysis (Weisel et al. 2021) concluded that although some trials showed potential of apps targeting mental health symptoms, using smartphone apps as standalone psychological interventions cannot be recommended based on the current level of evidence at this time. Specific to perinatal mental health apps, a systematic review by Feldman et al. (2021) examined both the academic literature and commercial app stores for mobile health interventions targeting perinatal mental health. The authors concluded that in terms of quality, both the academic and commercial offerings were of low quality, and there was minimal and mixed research on any improvement in mental health symptoms associated with the use of these apps.

Of note, the impact of digital interventions is limited by their ability to engage users, which appears to be a challenge for many apps. A systematic review by Baumel et al. (2019) examined usage patterns of 93 mental health apps relying on independently collected data. Findings revealed strikingly low engagement levels; the median percentage of daily active users (open rate) was 4.0% (IQR 4.7%) and the medians of 15-day and 30-day app retention rates were 3.9% (IQR 10.3%) and 3.3% (IQR 6.2%), respectively.

Fortunately, innovative work is being done in the MIT’s Affective Computing group to specifically address this issue of low long-term engagement among mental health apps. They have developed The Guardians: Unite the Realms  – a mobile game that incentivizes players to regularly complete “real-world“ tasks in exchange for “in-game” rewards that have immediate and intrinsic value in the game. The design of the mental health intervention in the game is informed by behavioral activation theory – an evidence-based framework that helps individuals reduce depressive symptoms by encouraging them to engage in adaptive and pleasant behaviors (Lejuez et al, 2001). 

Initial research on over 7,000 users of The Guardians app has found interaction data to be more than double the average retention levels of most digital mental health interventions (Ferguson and Lewis et al., 2021).   The Guardians app is the winner of Fast Company’s 20201 Innovation by Design award in the Wellness category.

We are excited to announce that we have teamed up with collaborators at the MIT Affective Computing group to explore how this novel app could benefit women experiencing depression during pregnancy. CLICK HERE for more information on our pilot study of The Guardians app during pregnancy – we’re now recruiting!

Rachel Vanderkruik, PhD, MSc



Baumel, A., Muench, F., Edan, S., & Kane, J. M. (2019). Objective User Engagement with Mental Health Apps: Systematic Search and Panel-Based Usage Analysis. Journal of medical Internet research, 21(9), e14567. 

Feldman, N., Back, D., Boland, R., & Torous, J. (2021). A systematic review of mHealth application interventions for peripartum mood disorders: trends and evidence in academia and industry. Archives of women’s mental health, 1–12. Advance online publication. 

Ferguson, C.* and Lewis, R.*, Wilks, C., Picard, R.W.; The Guardians: Designing a Game for Long-term Engagement with Mental Health Therapy; IEEE Conference of Games 2021 *Joint first authors

Lejuez CW, Hopko DR, and Hopko SD, “A Brief Behavioral Activation,” Behavior Modification, vol. 25, no. 2, pp. 255–286, 2001.

Weisel, K.K., Fuhrmann, L.M., Berking, M. et al. Standalone smartphone apps for mental health—a systematic review and meta-analysis. npj Digit. Med. 2, 118 (2019). 

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