SAN FRANCISCO — Making medicines isn’t about aesthetics. Your pill doesn’t need to be pretty to work.
But with mental health apps, good design is half the battle. App makers have to be able to translate traditional therapy techniques into easy exercises that people can flip through on their phones. They have to make it responsive and, in theory, they have to make it effective. They also have to convince people the app is something they can trust — and can turn to when they’re feeling anxious.
That can take a village: To build Daylight, an app for anxiety, one digital health company relied on psychologists, animators, podcasters, designers, scriptwriters, product managers, and software engineers. The creators, Big Health, even called in a longtime Pixar animator and the former executive producer at “Radiolab” for reinforcement.
“We really think about what the underlying active ingredients are within proven therapies … and then put that into an experience that’s delightful and entertaining, so that people can actually absorb it and apply it to their own lives,” said Lily Cheng, director of product design at Big Health.
The jury’s still out on whether Daylight can help people with anxiety. The company is running its first clinical trial now and is preparing to launch another study soon. They’re looking at whether using Daylight can help bring down users’ scores on the GAD-7, a common clinical test for generalized anxiety disorder. The app is currently only available to research participants and some individuals whose insurance already covers the company’s first app, Sleepio. That app has been shown to reduce symptoms of insomnia.
If those studies show Daylight can help curb anxiety, it could help the app stand out in a sea of digital mental health tools that haven’t been well-studied. A study published earlier this year in Nature Digital Medicine found that while mental health apps often used scientific language to tout their benefits, almost none provided any high-quality research to back up those claims.
“The vast majority of mental health apps simply don’t have evidence,” said Dr. John Torous, the director of the digital psychiatry division at Beth Israel Deaconess Medical Center in Boston. Torous isn’t involved with Big Health.
But having good evidence isn’t enough to make an app useful, Torous said. The secret is also in getting users to stick with the program. That’s where design comes into play.
“You really have to think about how you’re going to build, design, and implement this app in the earliest stages,” he said.
Each exercise in the app is the product of a back-and-forth between Big Health’s clinicians and its storytellers. The design team works with clinicians to tease out the core elements of a technique known as cognitive behavioral therapy that need to be communicated in an exercise. Then, they mull over metaphors, write out scripts, and draw storyboard sketches.
With every activity in Daylight, they’re trying to strike a balance: instructions that are thorough but not overwhelming, care that’s compassionate but clinically meaningful, interactions that are serious but inject a little playfulness. In one exercise that involves visualizing a worry and ways to cope with it, the narrator quickly acknowledges what the listener might be thinking — “No, thanks! That sounds awful!” — before rattling off the reasons a user should give it a try.
“A lot of what we’re doing from, from scripting to the animation, is really about trying to show that we really understand what you’re going through,” said Kelvin Kwong, VP of product at Big Health.
Take, for example, an exercise on the app called “tense and relax.” It’s designed to help people relax their muscles and in turn, start to relax their brains.
When a user picks that exercise, they see a bell-shaped character with skinny black lines for arms and legs looking around fretfully, its eyebrows furrowed. Its head swells into a big circle as the narrator explains that while it’s easy to think anxiety is “all in your head,” it’s sometimes fueled by tension in your body, too. The narrator says a simple activity might help: tense all of your muscles up tightly, and then let it all go.
The character follows along, its tiny stick arms trembling as its muscles squeeze.
“I actually want you to tense up. That way, when you release all that tension, you’ll benefit from a natural relaxation response,” the narrator explains as the character shrinks back down to size.
Even the drawing of the character is carefully thought through. Initially, the stick figure was just a rough sketch. But the design team quickly realized that the single-line arms and legs worked surprisingly well.
“People are able to actually see themselves in it, because it’s so simple,” said Neil Simpson, the creative director of Big Health. It doesn’t have a gender or a name, which makes it easier for people to map themselves onto the character, he said. A few added touches — like the expressive eyebrows — give it more of a human feel.
“This is a [character] who is going through the same things you’re going through. We understand that and we can empathize with that. But we can also show you how this we’re going to help this character feel a little bit better and take control of what’s going on,’” Simpson said.
In designing Daylight, the Big Health team is taking much of its playbook from podcasts. They want to mimic the experience of feeling like you’re friends with the host of your favorite podcast — even though you’ve never spoken to that person.
“Somehow there’s a level of intimacy that’s developed. And we want to use that to help the person trust this program so that they can actually get better,” said Kwong.
A big part of that intimacy is making sure the voice of the app strikes just the right tone. So it’s fitting that the app’s narrator is Ellen Horne, a longtime podcast veteran and former executive producer of “Radiolab.” Simpson reached out to Horne after recognizing her name in the comments on a friend’s Facebook post. He wanted to pick her brain about storytelling on Daylight. She shared some advice on making stories resonate with readers and recorded some scratch tracks of the narration.
Meanwhile, the Daylight team was on the hunt for a voice actor. And as they listened to the tapes, one stood out as the clear favorite: Horne’s. So they had her do it over and over again. They had her record the script looking in a mirror and sitting in a room talking to someone else. Another time, Horne had to read off the script three times in a row, then tossed it aside and talked from memory. The team was trying to hit the sweet spot of sounding warm and genuine while still effectively delivering therapy.
Big Health has tried to inject that human-ness into other parts of the app, too. When users log in, they’re greeted by name and asked how they’re doing. It’s the kind of small talk that might start a therapy session. Depending on how a person answers, the app might recommend a certain exercise as a starting point that day.
And when a user finishes an exercise, the narrator sometimes tosses out a turn of phrase that sounds more like it came from your mom than from an anxiety app, like “See ya later, alligator!”
“It just feels warm,” said Simpson. “It feels human and helpful.”