The Use of Smartphone for Bipolar Disorder Patients: A Systematic Review

Bipolar is a mood disorder characterized by extreme swings between feelings of happiness and sadness. Based on WHO data, around 60 million people experience bipolar disorder. Bipolar disorder causes functional, psychosocial functioning, quality of life impairments and even the risk of suicide. The large number of smartphone users and the increasing computing power of mobile devices can be used as a reference in using smartphones for bipolar disorder. This systematic review aims to determine the use of smartphones for patients with bipolar disorder. The systematic review method was applied to search articles in electronic databases such as PubMed, Science Direct, and SpringerLink published in 2017-2021. The keywords used in the search were "smartphone", "bipolar disorder" using the Boolean "AND". Articles reviewed were those which met several inclusion criteria such as relevant to the study objective, written in English, not an article review, and free full text. An analysis towards 16 relevant articles found that the use of smartphones for patients with bipolar disorder was intended to measure and monitor signs and symptoms, as a medium for psychotherapy, and to increase adherence to medication. This can be a reference for healthcare workers in carrying out monitoring and management programs for bipolar disorder.


INTRODUCTION
Bipolar disorder is a mood disorder characterized by extreme swings between feelings of happiness and sadness.Because of these changes, bipolar disorder is also called manic-depressive, in which the patient suffers from periods of depression but also suffers from periods of mania (excitement or irritability, excessive energy, lack of sleep, fast speech, feeling very up, poor judgment and impulsivity) 1 .
Bipolar disorder occurs in many countries in the world.Based on the WHO report, there are around 60 million people affected by bipolar disorder 2 .Individuals with bipolar show symptoms of mania, where they behave impulsively, feel invincible and often engage in risky activities such as suicide 3 .In addition, neurocognitive dysfunction and depressive symptoms in bipolar disorder can lead to functional impairment 4,5 .
In addition to functional impairment, bipolar disorder also have a serious impact on psychosocial functioning and quality of life 6,7 .Therefore, innovations are required in the management of such disorder.
The rapid development of technology is also followed by technological developments in the health sector, one of which is regarding mental health.Various technologies such as smartphones have been successfully adopted in the context of mental health 8 .There is a rapid growth of Smartphone users in Indonesia.Based on data derived from the Ministry of Communication and Information, 89% of Indonesia's population uses smartphones 9 .
There are sensors embedded in smartphones so that they can collect a large amount of objective information to identify behavioral patterns of symptoms as well as physiological signs.Such advantage leads to the potential to provide new insights about mental disorders 10 .In addition, there are means to collect various sensor data on smartphones, so as to be able to capture disease-related behavioral information 11 .
The large number of smartphone users and the increasing computing power of mobile devices can be used as a reference in using smartphones for the mental health sector, especially for bipolar disorder.This systematic review aims to determine the use of smartphones for patients with bipolar disorder.

METHOD
This article writing applied literature review method through electronic searches on several databases such as PubMed, Science Direct, and SpringerLink which were published in 2017-2021.The keywords used in the search

Figure 1. Article Search Flowchart
were "smartphone", "bipolar disorder" using the booleand "AND".The keywords used in the search were "smartphone", "bipolar disorder" using the Boolean "AND".Articles reviewed were those which met several inclusion criteria such as relevant to the study objective, written in English, not an article review, and free full text.
Article identification was performed using the PRISMA guidelines with the following steps: (1) determined the research topics to be reviewed, (2) determined research questions, (3) determined keywords for the article search process, (4) searched for articles with predefined keywords in the selected databases, (5) identified multiple articles from the databases, (6) screened relevant articles based on titles and abstracts, (7) screened full text articles using inclusion criteria (8) determined the articles to be analyzed.Figure 1

RESULTS
The database search results obtained 307 articles which were further selected.The selection results obtained 16 relevant articles for further analysis.The results of the analysis are described in table 1

DISCUSSION
Various smartphone applications that have been developed showed that there were creative information technology-based innovations that were useful for patients with bipolar disorder.Each of these applications had useful features such as measuring and monitoring signs and symptoms, as a medium for psychotherapy, and increasing adherence to medication.

Measuring and Monitoring Signs and Symptoms
The heterogeneity of symptoms of bipolar disorder makes it difficult to predict the course of the disease.As a result, patients often lack knowledge and are often unaware of the mood swings that lead to relapses 28 .To prevent this, accurate information about the timing of the affective phase transition must be made available to patients and healthcare professionals.This information can enable service providers to intervene as soon as symptoms appear.
Information from the patient's daily life can help provide earlier and more reliable predictions of the affective phase transition that will occur in bipolar disorder 17.Smartphones are easy-to-use and low-cost devices that can be used to assess information in patients' daily environment 13 .In addition, there is great interest among patients with mental health problems in monitoring symptoms through mobile applications 26 .
Applications on smartphones could record and process behavior related to accelerometers, global positioning systems (GPS), exercise, physical activity, sleep, work and leisure time, phone calls, and digital communications 15,18,20,24,25 .Interpretation and statistical analysis of data could be carried out by the application system, so that it might lead to more personalized diagnoses and interventions 29 .

As a Medium for Psychotherapy
Psychotherapy is the first-line intervention to prevent relapse in bipolar disorder 30 .However, there are several obstacles to the success of therapy.One of the main problems is the nature of face-to-face therapy which requires the patient and therapist to be at the same time.It requires a strong commitment to such care making it difficult for many patients, especially since therapy is given over a long period of time (eg, 4-6 months) and sessions take place at fixed dates and times (eg, once a week, lasting 1 hour) 31 .Such characteristics of therapy caused the high dropout rate.In addition, to implement certain intervention programs, there should be specialized therapists and there was a gap between supply and demand 32 , and hence in many health systems, the provision of such care was limited 31 .Information and communication technology is an opportunity to develop smartphone-based psychotherapy.This technology can overcome some of the limitations of face-to-face care.Smartphonebased psychotherapy is easily accessible and the time for therapy can be adjusted according to the needs and availability of each user 23 .In addition, such intervention programs offer the possibility of patient self-monitoring with twoway feedback between the patient and the healthcare provider 26 .
Smartphone-based psychotherapy in the form of learning sessions contained multimedia content such as video tutorials, presentations, audio, and pdf documents as well as psychotherapy exercises that could be performed anytime and anywhere 23,26 .In addition, smartphone-based psycho-education provided a way to remotely monitor patient status by enabling the collection of physiological/biometric parameter data so that patients could be actively involved in the treatment process 23 .

Improving Adherence to Medication
A previous study showed that half of patients with bipolar disorder did not take their medication as prescribed (33) .Low level of adherence increase the risk of mood swings, cognitive impairment, depressive sequelae, suicide, as well as increased use of health care and poor quality of life 33,34 .
Several things that hinder patient nonadherence to treatment were costs and accessibility of health care 35 .One potential strategy to increase adherence to and also increase the accessibility of treatment is intervention using a smartphone.Several previous studies revealed that applications on smartphones such as BIPOLIFE® and EMI could improve adherence to medication and attitudes toward treatment 14,22 .
Applications on smartphones could increase adherence through psychoeducational messages and also through observation on the consequences of changes in mood and energy in the form of avatars.Some patients reported that such features helped them realize the importance of the quality of life and adherence to medication in the management of bipolar disorder 14,22 .

CONCLUSION
Smartphones could be used for bipolar disorder patients for certain functions such as measuring and monitoring signs and symptoms, as a medium for psychotherapy, and increasing adherence to medication.This can be a reference for healthcare workers in carrying out monitoring and management programs for bipolar disorder.
presents the search flowchart.

Table 1 . Reviewed Articles Writer/Year Study Objective Study Design/Samples Findings
.