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APP REVIEWS

Anxiety in Adults

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Dr. Matthew Cruickshank
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Anxiety disorders are extremely common with a lifetime prevalence as high as 31% and a 12-month prevalence around 18% [1]. They are associated with an increased risk of major depressive disorder and are often comorbid with substance use disorder and other mental illness. Anxiety disorders cause substantial functional impairment to the individual and a significant burden on society due to decreased work productivity and greater use of healthcare resources. Anxiety disorders have been shown to be independently associated with various physical conditions such as migraine headaches and gastrointestinal disease. The presence of comorbid anxiety with physical problems can increase the impact of, and disability from, the physical problem [2].

Anxiety disorders are well known to family physicians and are encountered regularly in clinical practice. Although they can be effectively treated, there are often barriers to diagnosis and treatment. As a result, up to 40% of patients with anxiety are left untreated. The most recent Canadian clinical practice guidelines for the management of anxiety recommend tailoring treatment based on patient preference, motivation, comorbid conditions and availability of counselling resources [1]. One of the treatment barriers often encountered for psychological treatment is the ability of patients to afford formal treatment with a provider. Pharmacologic treatment can be effective in some of these patients, but not all patients benefit and some prefer to avoid medication altogether. Cognitive behavioural therapy (CBT) is well established as an effective treatment for a variety of anxiety disorders. Mindfulness-based therapy has also been shown to be a helpful treatment for anxiety [1]. If patients cannot access these tools the success of their treatment may be limited. Most family doctors do not have the training or time to offer these treatments themselves. Less formal approaches such as self-help books and apps offer the potential to help fill in this treatment gap. App-based therapy can also incorporate interactive and media-rich experiences that can enhance therapy.

In this review we have identified four smartphone apps that could be helpful for individuals with anxiety disorders. One of the apps is comprehensive in its scope and has both CBT and mindfulness tools. One of the apps focuses on guided meditation while another focuses on exposure-based CBT. The final app offers users some basic CBT tools.

Apps Reviewed

Pacifica
4.5 stars4.5 stars4.5 stars4.5 stars4.5 stars
Headspace
4 stars4 stars4 stars4 stars4 stars
AnxietyCoach
3 stars3 stars3 stars3 stars3 stars
Companion
3 stars3 stars3 stars3 stars3 stars

AnxietyCoach

3 stars3 stars3 stars3 stars3 stars

AnxietyCoach was developed by Dr. Stephen Whiteside and Dr Jonathan Abramowitz, both clinical psychologists with expertise in anxiety treatment. The focus of the app is providing users with an interface for self-guided exposure therapy. It does this by helping users create ‘To Do Lists’ of exposures and then helps to step them through their list. Once an exposure is started it continues until a reduction in anxiety takes place. Once an item on the list has been completed a user is then ready to move onto the next item on their list, gradually proceeding to more intensive exposures. The efficacy of exposure therapy, a form of CBT, has been well established in helping to reduce inappropriate anxiety responses [3]. The app has the potential to benefit users but it is not clear how willing individuals with significant anxiety would be to undertake exposure therapy with this app alone as their guide. The app would benefit from a formal evaluation of its effectiveness. It has a dated appearance with text formatting issues and is overdue for an update. It would also benefit from a multi-media approach to help engage users. This app could be useful to individuals who are proceeding with exposure therapy with a therapist who are looking for a way to help track their progress. It may also be useful to individuals wanting to try exposure therapy on their own.

Detailed Review View All

Features

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The focus of this app is exposure therapy. The app provides users with pre-populated lists of common fears and anxieties that can be used to form their personal ‘To Do List’ of graduated exposures, each step meant to be more anxiety-provoking then the last. Users can then work through their list one item at a time. Users rate their anxiety levels prior to exposure and every two minutes during an exposure and remain with an exposure until anxiety drops to below 50% of their baseline. Once they have completed one step they can move onto the next item on their list. The app also includes a text only overview of the basics of anxiety disorders as well as a description of CBT as a treatment.

Effectiveness

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The app is based on exposure-based cognitive behavioural therapy which is well established as an effective treatment of anxiety disorders. It is not clear, however, if a stand-alone app is an effective way of implementing exposure-based therapy. The effectiveness of the app has not been formally established.

Usability

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The app is generally simple and intuitive to use. It only uses text and simple graphics which makes it less immersive than some of the other anxiety apps reviewed.

Privacy & Security

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A clear privacy policy is presented at the first launch of the app. The app collects data entered by the user with the stated intention of using it to perform research that will help refine the application and develop other medical education tools. The policy clearly states that it does not collect any personally identifiable information about users or their devices.

Reliability

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This app was launched in 2012 and has received a few updates since. It was last updated in October 2017. While testing, the app text would occasionally be displayed with formatting errors, making it unreadable. The app also has a dated appearance.

Accessibility

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The app is only available in the Apple store. It has a one-time purchase price of $6.99 which some users might find high for the tools it provides. The language used in the app would be easy to understand for most users.

Companion

3 stars3 stars3 stars3 stars3 stars

Companion is an app created by a psychologist and by someone who had previously benefited from cognitive behaviour therapy for anxiety. The app was created to give users mobile tools to help manage their anxiety whenever it is needed the most. The app offers a basic thought-reframing tool based on cognitive behaviour therapy principles. The tool is designed to help users recognize their negative thoughts and reframe them in a more positive way. The app offers a few relaxation tools including two audio-guided meditations. It offers a learning section with text based overview of anxiety and treatment options for it. The app is limited in the scope of its tools and only scratches the surface of cognitive behaviour therapy. The app may be useful as a companion for individuals undertaking more formalized cognitive behaviour therapy or for individuals with mild anxiety disorders. It would not be suitable as a stand-alone tool for individuals with moderate to severe anxiety disorders.

Detailed Review View All

Features

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This app offers a thought reframing tool based on principles of cognitive behaviour therapy, relaxation tools and educational text. The reframing tool asks users to identify a trigger that caused them to have a negative thought. It asks them to choose between four negative thought processes that their negative thought falls into and then asks them to reframe their thought in a positive way. Once completed it allows users to create a reference card for future reference of what they learned in the reframing process. The app has three relaxation tools: a guided breathing tool, two audio-based guided meditations and small brain games meant to distract users from their anxieties. Finally the app offers a text based overview of anxiety, its causes and its treatments.

Effectiveness

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The app is based on techniques that are effective for treating anxiety disorders but are limited in their scope. It is unclear if these tools delivered in an app-based format could be effective in helping to treat anxiety disorders. The effectiveness of the app has not been formally established.

Usability

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The app has a simple and intuitive interface. It is easy to navigate and pleasant to use. Throughout the app an easily identified ‘EXPLAIN THIS’ button is available that launches a text based explanation of the tool being used. The app could benefit from additional multi-media to help engage users.

Privacy & Security

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A basic privacy statement is available within the app. It states the company reserves the right to anonymously track and report a user’s activity inside the app in order to create improvements to the app. It does not comment on how this data is stored or if it can be sold to third parties.

Reliability

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The app was launched in 2014 and was last updated in 2015. It is unclear if any further work or updates on the app are planned. The app was very reliable during testing, working well on the latest iOS with no crashes or other issues identified.

Accessibility

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This app is available as a free download but is only available in the Apple store. The language used in the app is simple and would be easy to understand for most users.

Headspace

4 stars4 stars4 stars4 stars4 stars

Headspace is a guided meditation app created by Andy Puddicombe, an ordained Buddhist monk. Andy Puddicombe created the platform with the goal of teaching meditation and mindfulness to as many people as possible because he believes they will help improve the health and happiness of the world. The app has millions of users so it may in fact be helping with this ambitious goal. The app is a comprehensive and media-rich approach to guided meditation and is perfect for both introducing meditation to users not previously familiar with the practice and for users with previous mindfulness experience who are looking to deepen their skills. Although this app probably could not be used as a standalone treatment for most individuals with an anxiety disorder, it is a great tool to supplement other treatments.

Detailed Review View All

Features

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This app offers audio-based guided meditation practices focused on specific health and wellness topics including anxiety, stress and sleep. The meditations start with an introduction around the focus and goals of the meditation as well as education on new mindfulness skills. They then proceed to guide the user through their practice. The app also offers background instructional text and videos spaced between the sessions to help users understand the principles of mindfulness and meditation and broaden their skills. The app integrates with the Apple HealthKit to store mindful minutes in the app. Although the app does a great job delivering mindfulness meditation it does not include any cognitive behaviour therapy resources which limits its use as a stand-alone treatment for anxiety disorders.

Effectiveness

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The app is based on mindfulness-based meditation which has positive research on helping to reduce symptoms of anxiety for individuals with anxiety disorders. However this therapy is not as extensively studied as cognitive behavioural therapy for anxiety treatment. The Headspace team has been collaborating with many research universities in evaluating the app on various health outcomes. There have been many positive outcomes but none of the published research is specific to anxiety treatment. The Headspace website states there are four ongoing research studies that are studying the app’s effect on anxiety.

Usability

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The user experience of this app is exceptional. As a new user inexperienced with mindfulness, it is easy to get started and oriented. The interface is clean, simple and pleasant to use.

Privacy & Security

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A privacy statement is available for the app that states it may collect personal information including name, e-mail address, telephone, payment information and information about product usage. The policy states the company follows generally accepted standards to protect personal information and further information can be obtained upon request from the company. Personal information is not provided to third parties without specific consent.

Reliability

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The app worked very well in testing with no crashes or other reliability concerns. The app is frequently updated with 18 updates alone in the last year.

Accessibility

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The app is available in both the Android and Apple store. It is a free download but requires a $17.99 monthly subscription fee to continue using the app after a short trial period. The app uses videos, audio and text that would be easy to understand for most users.

Pacifica

4.5 stars4.5 stars4.5 stars4.5 stars4.5 stars

Pacifica was created with the goal of bringing well-proven therapies for stress, anxiety and depression to individuals who are not able to access traditional therapy because of barriers such as cost and stigma. One of the founders has suffered with anxiety himself and has experienced firsthand improvement with effective treatment. The Pacifica team has a clinical psychologist on staff and a scientific advisory board to help ensure the app is driven by evidence-based treatments. The app includes CBT tools as well as mindfulness and wellness tools in a well-planned and well-organized way to help users treat their anxiety disorders. The app encourages users to set goals and work to accomplish them, but otherwise it does not offer more involved exposure therapy tools. Pacifica could be a great app for most individuals with anxiety disorders who are willing to take the time to engage with the app.

Detailed Review View All

Features

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This app stands out for providing well-structured cognitive therapy tools to help users be better able to challenge the thoughts and feelings they experience. The app provides audio-based ‘Guided Paths’ learning modules that link to practical exercises to help solidify the concepts. The app also offers guided audio-based meditations and mindfulness practice. The app offers a variety of wellness tools to track mood and other health parameters. There is an active and supportive user community built right into the app. The app integrates with the Apple HealthKit to track mindful minutes. The app is limited in addressing exposure-based CBT but does encourage users to confront their anxieties.

Effectiveness

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This app does a very good job of implementing both CBT and mindfulness therapies. These therapies have been shown to be effective in treating anxiety disorders; it is very likely that this app would be effective for many users. Unfortunately, there are not yet any published research trials on the effectiveness of the app. The Pacifica website states there is an ongoing randomized controlled trial being done through a partnership with University of Minnesota and that the pilot showed impressive effect across multiple measures.

Usability

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The app has excellent usability. It offers a clean and organized interface while still delivering a comprehensive tool. Audio and video are integrated seamlessly into the app and exercises are well organized and explained.

Privacy & Security

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A privacy statement is readily available for the app. It states that personal information is used to manage accounts and provide services. Personal information may be used for limited marketing purposes such as sending information about the company or partners. It states that the company does not collect personal information for the purpose of sale of such information in a way that identifies the individual.

Reliability

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The app worked very well in testing with no crashes or other reliability concerns. The app is frequently updated with bug fixes, new features and improvements in usability.

Accessibility

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The app is available in both the Android and Apple store. While the download is free, there is an $8.49 monthly subscription fee to use the app. The app uses videos and text that would be easy to understand for most users.

Patient Experiences

It’s the most wonderful time of the year. Isn’t it?

That’s what Andy Williams’ recording of the 1963 tune, which celebrates get-togethers between friends and families at the Christmas season, would have us believe. But amongst those who observe Christmas – or Hanukkah, Kwanzaa, Hogmanay, Yule or any of the other tradition-rich celebrations that populate this time of year – anxiety can be exacerbated by the demands of the season. We angst about money spent, work time missed and our determination to magically see every friend and family member and make them happy. So while there’s an actual decrease during the holiday in utilization of psychiatric emergency services and admissions, self-harm behaviour and suicide attempts/completions, according to The Christmas Effect on Psychopathology, there is an increase in dysphoric moods like anxiety, irritability, fear and brooding.

A few years back, Greenberg Quinlan Rosner Research, a leading U.S. polling firm, surveyed Americans to find out about holiday stress. Overall, 38 per cent of respondents reported that stress increased at the holidays but, amongst lower middle income families, about 53 per cent reported higher stress levels. Not surprisingly, lack of money, lack of time and the pressure of buying and giving gifts were the leading stressors. More than half of all respondents reported that work was the leading source of stress both in terms of money and time. More women (44 per cent) than men (4 per cent) reported increased stress. Finally, 28 per cent of women and 32 per cent of men reported they were somewhat likely to drink alcohol to reduce stress while 57 per cent of women and 55 per cent of men reported they were somewhat likely to turn to food for comfort.

Holiday anxiety is nothing new but there is a new twist: at least one of this year’s guides for stress-relief gifts not only includes the familiar magnetic desk sculptures and Zen gardens but apps to help us de-stress.

References

  1. Katzman, Martin A., et al. “Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders.” BMC psychiatry 14.1 (2014): S1.
  2. Sareen, Jitender, et al. “Disability and poor quality of life associated with comorbid anxiety disorders and physical conditions.” Archives of internal medicine 166.19 (2006): 2109-2116.
  3. Kaczkurkin, Antonia N., and Edna B. Foa. “Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence.” Dialogues in clinical neuroscience 17.3 (2015): 337.
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