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SMART works in psychosis

Smart applications that use mobile devices and computers to track symptoms and facilitate treatment engagement, and self-management should not only improve mental health outcomes but also reduce care costs – both of which are important in the management of psychosis. Use of mobile health technology to help those individuals experiencing or at high-risk of psychosis was the topic covered during an encouraging and optimistic symposium at SIRS 2018.

Treatment engagement and symptom tracking

“Between sessions data collection might improve in-session care,” Laura Tully, California, USA, told delegates. For example, regular monitoring for relapse predictors via mHealth platforms could alert both provider and client to impending relapse and facilitate early intervention. Dr Tully described two studies that used mobile platforms to determine the feasibility of such an approach in Early Psychosis (EP) research and in outpatient settings.

Between sessions data collection might improve in-session care

In the first study, a smartphone app plus clinician Dashboard* were provided as an add-on treatment tool in the University of California, Davis Early Psychosis (EP) Program. Paid participants completed daily and weekly surveys that monitored mood, symptoms, and other relevant factors via the app. Symptom assessments were made with research staff during monthly treatment sessions using the Dashboard for up to 14 months.

Of the 143 clients enrolled in the UC Davis EP program, 76 enrolled in the study. The average participation time was 183 days; 77.3% completed the weekly and 69% the daily surveys.  A total of 70 (92%) patients contributed to the validity assessment. There were statistically significant correlations between self-reported and clinician-rated positive symptoms and depression/anxiety symptoms. Furthermore, it appears that an increase in depression, anxiety and visual perception abnormalities predicts an increase in positive symptoms 1 week later. This suggests that use of the tool to predict onset of symptoms was feasible and provides self-reported data of a quality comparable to that obtained in clinical practice.

An increase in depression, anxiety and visual perception abnormalities predicts an increase in positive symptoms 1 week later

However, the next step was to see whether use of the tool was feasible in the clinic. Would health service providers as well as users find the tool feasible in everyday practice? Unlike the previous study, all those involved in this scenario were not being paid to test the tool.

EP individuals in 4 community outpatient EP clinics in Northern California downloaded an app on their smartphone and responded to daily mood and symptom surveys for up to 5 months. Treatment providers were able to view survey responses on a secure Web-based dashboard both during sessions and between appointments with EP patients.

Of those completing the satisfaction surveys, 27/41 (66%) EP patients and 11 of 13 (85%) service providers reported that they would continue to use the app as part of treatment services. However, 6/41 patients and 3/13 providers said that technological glitches were problematic during the survey. Dr Tully remained upbeat as such issues are addressable!

Of those completing the satisfaction surveys, 27/41 (66%) EP patients and 11 of 13 (85%) service providers reported that they would continue to use the app as part of treatment services

Rapid identification and referral

Tara Niendam, California, USA, presented the initial findings from a two-phase, community-based, cluster-randomized controlled trial. This study was designed to test two specific strategies to reduce Duration of Untreated Psychosis (DUP): through more rapid case identification by community referral sources via the addition of electronic screening of a 21-item prodromal Questionnaire Brief (PQ-B) to targeted provider education and through more timely enrollment and retention in care by improving initial engagement in FEP outpatient services through community-based, mobile, telepsychiatry.

A total of 24 school, community, and primary care sites in Sacramento, California were randomized to receive either targeted education and electronic screening (Group 1) or targeted education alone (Group 2) for psychosis symptoms. In Group 1, high scorers on the electronic screening were referred for evaluation; low scorers were either monitored or referred, if appropriate. In Group 2, patients with relevant symptoms were referred for evaluation.

Electronic screening is feasible in the community

Results showed electronic screening is feasible across various community settings and significantly increases identification of those experiencing psychosis-spectrum symptoms compared to targeted education alone. However, electronic screening did not significantly improve identification of FEP or improve DUP. Dr Niendam reported that some health care providers were introducing the tool as the ‘schizophrenia screener’ which could create barriers to its acceptance by clients.

Introducing the tool as the ‘schizophrenia screener’ could create barriers to its acceptance

Functional recovery – generating momentum

Although interventions can reduce rates of transition to psychosis in Ultra High Risk (UHR) subjects, poor functional outcome persists in this group, regardless of whether they experience transition to psychosis or not. Barnaby Nelson, Melbourne, Australia, described the “MOMENTUM” pilot study which investigated the safety, acceptability, and feasibility of an online social media-based intervention - MOMENTUM - specifically designed to enhance social functioning in UHR subjects.

MOMENTUM was devised in close collaboration with its end users and comprises a suite of interventions that incudes peer-to-peer social networking, tailored therapeutic interventions (including mindfulness and self-compassion), expert and peer-moderation, and a strength-based framework – the latter building on what users were good at to bolster their confidence and participation. 

MOMENTUM was devised in close collaboration with its end users and comprises a suite of interventions

Of the 15 UHR subjects recruited to the MOMENTUM 2-month pilot study, 13 were interviewed at follow-up (87%). System usage was high and 67% of users were actively engaged with the online system over duration of the trial. All participants reported a positive experience using MOMENTUM and would recommend it to others; 93% considered MOMENTUM to be helpful; 64% of users felt more in control of their symptoms; and 57% felt more socially connected. Importantly, no incidents, reports or adverse events occurred during the pilot study and all participants reported feeling safe.

MOMENTUM works in UHR patients

Analysis revealed a significant increase in social functioning (P < 0.001; d = 2.39) and satisfaction with life (P = 0.03; d = 0.48) at follow-up. There was a statistically significant increase in therapy mechanisms directly targeted by MOMENTUM including strengths usage, mindfulness skills, and components of social support. System usage is associated with improved social functioning, social support, and strengths usage. Thus, MOMENTUM appears to be working.

Analysis revealed a significant increase in social functioning and life satisfaction

The next stage, as Professor Nelson reported, will be to compare MOMENTUM with treatment-as-usual in a randomized controlled trial. To this end, 220 subjects will be recruited. He also pointed out that it also remains to be seen whether the improvements gained through MOMENTUM can be maintained.

Self-management is feasible – if it’s not too repetitious

Hidalgo-Mazzei, London, UK, described the feasibility of delivering a psychoeducational treatment program to facilitate self-management in bipolar disorder. The SIMPLe platform is accessible from any internet enabled device and provides symptom monitoring and personalized psychoeducational content in Spanish, Italian, and French.

The SIMPLe feasibility study was positive, suggesting that self-management using mobile devices is possible. However, he noted that an implementation feasibility study - SIMPLe 1.5 - has recently been trialed with slightly disappointing results. Of the 201 patients accepted onto the study, just 68 were still using the system after 6 months. So while patients were happy with the device, they were gradually disengaging. ‘Too repetitious’ was one criticism. However, the feedback collected is being carefully considered and will no doubt be implemented to good effect when SIMPLe 2.0 is released.

Self-management using mobile devices is possible

*Secure web-portal where clinicians reviewed participants' data, including daily and weekly survey responses, survey completion rates, and passive data summaries (Niendam et al. Enhancing early psychosis treatment using smartphone technology: A longitudinal feasibility and validity study. J Psychiatric Res 2018; 96:239-246.)

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