Is Everyone Dropping out of Health Apps? Sustaining End User Engagement in Digital Mental Health

Poor user engagement with digital health apps is a widely reported and well-recognised problem [1].  We know that many people use health apps for a very short time and then disengage [2].  But there are tried and tested best practices around driving user engagement.

Dr Pauline Whelan is Digital Health Technical Lead at University of Manchester and a Director of CareLoop Health.

When we developed the CareLoop app which is used by people living with Psychosis and new parents at risk of postnatal depression, we adopted several approaches that to help support and sustain user engagement:

  • Co-design: co-designing the app with people with severe  mental illness (SMI) and clinicians: we didn’t assume we knew what people with SMI and their clinicians would want in an app; we worked with groups of people with SMI and clinicians intensively over many years to collaboratively design the digital tech.  We got it wrong a lot and we kept refining the functionality and the user interface until we met the needs of our end users.  This involved extensive testing and iterating of the digital platform in real-world clinical settings.

  • Understanding what engagement is really about: we understood from the start that supporting effective engagement with digital therapeutics isn’t about ensuring that end users log in to the platform all the time; it’s about ensuring that people use the digital tech to meet their needs and improve their clinical outcomes.  We wanted people to engage with the app ‘just enough’ to improve their outcomes.  We worked with service users and clinicians to understand what level of usage was acceptable and useful.

  • Making the tech relevant to the individual user: we designed the tech to be personalised to the individual; we prompt our users to respond to symptoms that are meaningful and relevant to them personally, including specific symptom questions that indicate they may be at risk and need additional help.

  • Making progress and goals visible: our apps provide people with severe mental illness insights into the trajectories of their illness that they haven’t had access to before.  People with SMI told us how much they liked being able to review their own symptoms over time, being able to track their progress and goals, and to gain personal insights between clinic appointments.  Clinicians told us that the CareLoop platform gave them vital insights into their patients’ symptoms that they had never previously been able to access.

Collaborating with UX designers, we designed for engagement from the start.  Across four clinical trials we demonstrated that people with severe mental illness kept returning to the CareLoop app because they found it helpful and simple to use. 

Not everyone is dropping out of health apps, and building a digital health product around four guiding principles can help support engagement. Firstly, apps need to be co-designed with the target population, and then refined and iterated to meet evolving user needs.  Secondly, the design needs to take into account how often and in what ways user engagement is required to meet the clinical goals.  Thirdly, apps need to be personalised and relevant to the individual end user.  Fourthly, they need to give the user something back from their engagement with the product.  Following these principles will help keep your app drop out rates low.


[1] Torous, J., Nicholas, J., Larsen, M. E., Firth, J., & Christensen, H. (2018). Clinical review of user engagement with mental health smartphone apps: evidence, theory and improvements. Evidence-based mental health, 21(3), 116–119.

[2] Torous, J., Bucci, S., Bell, I.H., Kessing, L.V., Faurholt-Jepsen, M., Whelan, P., Carvalho, A.F., Keshavan, M., Linardon, J. and Firth, J. (2021), The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality. World Psychiatry, 20: 318-335.