The EMPOWER blended digital intervention for relapse prevention in schizophrenia: a feasibility cluster randomised controlled trial in Scotland and Australia

Mental Health Professionals' Perspectives on Digital Remote Monitoring in Services for People with Psychosis

BACKGROUND AND HYPOTHESIS

Digital remote monitoring (DRM) captures service users' health-related data remotely using devices such as smartphones and wearables. Data can be analyzed using advanced statistical methods (eg, machine learning) and shared with clinicians to aid assessment of people with psychosis' mental health, enabling timely intervention. Such methods show promise in detecting early signs of psychosis relapse. However, little is known about clinicians' views on the use of DRM for psychosis. This study explores multi-disciplinary staff perspectives on using DRM in practice.

STUDY DESIGN

Fifty-nine mental health professionals were interviewed about their views on DRM in psychosis care. Interviews were analyzed using reflexive thematic analysis. Study Results: Five overarching themes were developed, each with subthemes: (1) the perceived value of digital remote monitoring; (2) clinicians' trust in digital remote monitoring (3 subthemes); (3) service user factors (2 subthemes); (4) the technology-service user-clinician interface (2 subthemes); and (5) organizational context (2 subthemes).

CONCLUSIONS

Participants saw the value of using DRM to detect early signs of relapse and to encourage service user self-reflection on symptoms. However, the accuracy of data collected, the impact of remote monitoring on therapeutic relationships, data privacy, and workload, responsibility and resource implications were key concerns. Policies and guidelines outlining clinicians' roles in relation to DRM and comprehensive training on its use are essential to support its implementation in practice. Further evaluation regarding the impact of digital remote monitoring on service user outcomes, therapeutic relationships, clinical workflows, and service costs is needed.

The era of digital mental health interventions: we know they can be effective but are they also safe?

Over the past two decades, digital mental health interventions (DMHIs) have seen a surge in studies with people experiencing mental ill-health, whether this be via web-based platforms, smartphone applications, text messages or other digital devices. Although DMHIs already demonstrate evidence of their acceptability and some of their effectiveness among different populations, the information about their safety is less clear. This Editorial reflects on a Delphi study by Taher and colleagues that explored the regulation of DMHIs and generated ten safety recommendations. We discuss these recommendations in the context of existing relevant literature and provide suggestions for further steps to advance research and policy on DMHIs in the UK and globally. Further dialog is needed, including the views and experiences of all key stakeholders, and particularly of people with lived experience, to ensure DMHIs are not only an acceptable and potentially effective treatment approach, but also safe for those that use them.

Mental Health Professionals' Technology Usage and Attitudes Toward Digital Health for Psychosis: Comparative Cross-Sectional Survey Study

Background

Digital health technologies (DHTs) for psychosis have been developed and tested rapidly in recent years. However, research examining mental health professionals' views on the use of DHTs for people with psychosis is limited. Given the increased accessibility and availability of DHTs for psychosis, an up-to-date understanding of staff perception of DHTs for psychosis is warranted.

Objective

In this study, we aimed to investigate mental health professionals' usage of technology and their perception of service users' technology usage; their views toward the use of DHTs for psychosis, including their concerns; and barriers for implementing DHTs in a mental health setting.

Methods

Two cross-sectional surveys were distributed to mental health care staff who had experience of working with individuals experiencing psychosis in the United Kingdom. Survey 1 (from April 2018 to September 2020) was distributed to 3 local UK National Health Service (NHS) trusts in Northwest England; survey 2 was administered nationally across 31 UK NHS trusts or health boards (from November 2022 to March 2024). The COVID-19 pandemic occurred between the 2 survey periods. Data were analyzed descriptively.

Results

A total of 155 and 352 participants completed surveys 1 and 2, respectively. Staff reported high levels of technology ownership and usage in both surveys. In general, staff expressed positive views regarding the use of DHTs for psychosis; however, barriers and concerns, including affordability, digital literacy, and potential negative effects on service users' mental health, were also reported. We did not find notable changes in terms of staff use of digital technology in clinical practice over time.

Conclusions

Staff sampled from a broad and diverse range expressed consistent optimism about the potential implementation of DHTs in practice, though they also noted some concerns regarding safety and access. While the COVID-19 pandemic is frequently regarded as a catalyst for the adoption of digital health care tools, the sustainability of this transition from traditional to digital health care appeared to be suboptimal. To address staff concerns regarding safety and potentially facilitate the implementation of DHTs, systematic evaluation of adverse effects of using DHTs and dissemination of evidence are needed. Organizational support and training should be offered to staff to help address barriers and increase confidence in recommending and using DHTs with service users.

Clusters of Patient Empowerment and Mental Health Literacy Differentiate Professional Help-Seeking Attitudes in Online Mental Health Communities Users

OBJECTIVES

Grounded in the Health Empowerment Model, which posits that health literacy and patient empowerment are intertwined yet distinct constructs, this study investigates how the interplay of these factors influences attitudes toward seeking professional psychological help in members of online communities for mental health (OCMHs). This while acknowledging the multidimensionality of patient empowerment, encompassing meaningfulness, competence, self-determination, and impact.

DESIGN AND METHODS

A cluster analysis of data gathered from 269 members of Italian-speaking OCMHs on Facebook has been performed.

RESULTS

Four profiles have been identified: dangerous self-managers (11.2%), effective self-managers (21.2%), disempowered (40.5%) and ambivalent empowered (27.1%). Clusters provided meaningful variations in help-seeking attitudes, also when controlling for depression and anxiety severity, F3, 265 = 11.910, p < 0.001.

CONCLUSIONS

The findings provided further evidence of the multidimensionality of patient empowerment. Considering the results, we discussed potential interventions aimed at enhancing the quality of OCMHs, tailoring to the unique characteristics of each cluster.

PATIENT OR PUBLIC CONTRIBUTION

Administrators and moderators of mental health Facebook communities-whether expert-led by mental health professionals or peers-played a key role in this study. They provided valuable insights during the questionnaire design process to ensure the questions were both relevant and appropriate for community members. These administrators and moderators also actively facilitated participant recruitment by creating and sharing posts, either video- or text-based, on community homepages. Furthermore, after completing the questionnaire, participants were encouraged to comment on the Facebook posts where the survey link was shared, mentioning that they participated and inviting other members to take part. This approach aimed to foster a sense of involvement and further promoted the survey within the community.

Utility of Consumer-Grade Wearable Devices for Inferring Physical and Mental Health Outcomes in Severe Mental Illness: Systematic Review

BACKGROUND

Digital wearable devices, worn on or close to the body, have potential for passively detecting mental and physical health symptoms among people with severe mental illness (SMI); however, the roles of consumer-grade devices are not well understood.

OBJECTIVE

This study aims to examine the utility of data from consumer-grade, digital, wearable devices (including smartphones or wrist-worn devices) for remotely monitoring or predicting changes in mental or physical health among adults with schizophrenia or bipolar disorder. Studies were included that passively collected physiological data (including sleep duration, heart rate, sleep and wake patterns, or physical activity) for at least 3 days. Research-grade actigraphy methods and physically obtrusive devices were excluded.

METHODS

We conducted a systematic review of the following databases: Cochrane Central Register of Controlled Trials, Technology Assessment, AMED (Allied and Complementary Medicine), APA PsycINFO, Embase, MEDLINE(R), and IEEE XPlore. Searches were completed in May 2024. Results were synthesized narratively due to study heterogeneity and divided into the following phenotypes: physical activity, sleep and circadian rhythm, and heart rate.

RESULTS

Overall, 23 studies were included that reported data from 12 distinct studies, mostly using smartphones and centered on relapse prevention. Only 1 study explicitly aimed to address physical health outcomes among people with SMI. In total, data were included from over 500 participants with SMI, predominantly from high-income countries. Most commonly, papers presented physical activity data (n=18), followed by sleep and circadian rhythm data (n=14) and heart rate data (n=6). The use of smartwatches to support data collection were reported by 8 papers; the rest used only smartphones. There was some evidence that lower levels of activity, higher heart rates, and later and irregular sleep onset times were associated with psychiatric diagnoses or poorer symptoms. However, heterogeneity in devices, measures, sampling and statistical approaches complicated interpretation.

CONCLUSIONS

Consumer-grade wearables show the ability to passively detect digital markers indicative of psychiatric symptoms or mental health status among people with SMI, but few are currently using these to address physical health inequalities. The digital phenotyping field in psychiatry would benefit from moving toward agreed standards regarding data descriptions and outcome measures and ensuring that valuable temporal data provided by wearables are fully exploited.

TRIAL REGISTRATION

PROSPERO CRD42022382267; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=382267.

The research gap in evaluating community-based mental health interventions in Korea: A comparative analysis with the United Kingdom

South Korea has historically relied on inpatient psychiatric care. Although the 1995 Mental Health Act aimed to promote community mental health services, progress in developing community-based interventions has been limited. This review aims to provide a concise analysis of the current state of research on evaluating community mental health care in Korea, employing a comparative perspective with the United Kingdom (UK), where community-based mental health approaches have been more extensively studied and implemented. On November 19, 2024, a literature search was conducted using PubMed. The search strategy combined keywords related to mental illness and community intervention with the terms "Korea" or "United Kingdom." The review focused on randomized controlled trials from both countries that assessed patient-level outcomes of community-based mental health interventions. The findings reveal a striking contrast: in Korea, only one randomized pilot trial focused on depression in older adults was found. In contrast, 69 studies were identified in the UK, including 13 pilot/feasibility studies and 56 main studies, with 38 of these addressing severe mental illness. This clear difference underscores the limited research and evaluation of community-based mental health interventions in Korea. The results indicate a pressing need for research to assess these interventions. Such research could guide policy reforms toward deinstitutionalization and help Korea strengthen its community-based mental health system in line with global trends.

Co-designing a low-intensity psychological therapy for fear of recurrence in psychosis using translational learning from fear of recurrence in oncology: protocol for intervention development for future testing in a feasibility study

INTRODUCTION

Fear of recurrence is a transdiagnostic problem experienced by people with psychosis, which is associated with anxiety, depression and risk of future relapse events. Despite this, there is a lack of available psychological interventions for fear of recurrence, and psychological therapies for schizophrenia are often poorly implemented in general. However, low-intensity psychological therapy is available for people who experience fear of recurrence in the context of cancer, which means there is an opportunity to learn what has worked in a well-implemented psychological therapy to see if any learning can be adapted for schizophrenia care. This article describes the design, methods and expected data collection of development, acceptab i lity, feasibility, a n d preliminary outcome signals for a copro d uced low-intensity psycholo g ical intervention targeting fear o f relapse in people with schizophrenia (INDIGO), which aims to develop an acceptable psychological intervention for fear of recurrence.

METHODS AND ANALYSIS

INDIGO will use a mixed-methods approach to co-design and deliver a model and treatment pathway for a psychological intervention for people diagnosed with schizophrenia who experience fear of recurrence. The study will consist of four stages. First, in-depth interviews with mental health staff and people diagnosed with schizophrenia (with a further social network mapping task for patient participants only) to develop the intervention. Second, in-depth interviews with people who have accessed the Glasgow Fear of Recurrence service and oncology staff will be conducted to inform further development of the intervention. Third, co-design workshops will be held with people diagnosed with schizophrenia and mental health staff to co-design intervention content and the treatment pathway. Finally, people diagnosed with schizophrenia will be presented with an intervention prototype and invited to complete 'think-aloud' interviews to gather further feedback so adaptations can be implemented.

ETHICS AND DISSEMINATION

The INDIGO study received ethical approval from East Midlands-Nottingham 2 Research Ethics Committee (24/EM/0124). The study received independent peer review prior to funding. This co-design study is expected to lead to a future feasibility study and, if indicated, a randomised controlled trial.

Characteristics and Outcomes of mHealth Interventions in Psychosis: Systematic Mapping Review

BACKGROUND

Mobile health (mHealth) interventions have gained popularity in augmenting psychiatric care for adults with psychosis. Interest has grown in leveraging mHealth to empower individuals living with severe mental illness and extend continuity of care beyond the hospital to the community. However, reported outcomes have been mixed, likely attributed in part to the intervention and adopted outcomes, which affected between-study comparisons.

OBJECTIVE

This study aimed to critically review outcome measures used to evaluate mHealth interventions for adults with psychosis in relation to the characteristics of mHealth interventions.

METHODS

A systematic mapping review was conducted. We searched PubMed, CINAHL, Embase, PsycINFO, and Cochrane Libraries from 1973 to the present. Selection criteria included randomized controlled studies of mHealth interventions in adults diagnosed with schizophrenia spectrum disorders. Reviewers worked in pairs to screen and extract data from included studies independently using a standardized form; disagreements were resolved by consensus with an independent reviewer. We report our findings in line with PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines.

RESULTS

A total of 1703 citations were screened; 29 publications reporting on 23 studies were included in this review. mHealth interventions for psychosis span a wide range, with psychological therapy being the most-deployed intervention (12/23, 52%), followed by psychoeducation (8/23, 35%) and active self-monitoring (8/23, 35%). Several mHealth interventions for psychosis targeted multiple pillars of biopsychosocial well-being (10/23, 43%); the bulk of interventions (16/23, 70%) incorporated features promoting users' self-management. The majority of mHealth interventions were delivered through applications (14/23, 61%) as the main medium and smartphones (17/23, 74%) as the main channel of delivery. Interventions were primarily administered in the outpatient and community settings (16/23, 70%); many were also blended with in-person sessions (11/23, 48%) or guided remotely (6/23, 26%) by persons, including health care providers or trained peer supporters. The severity of psychosis-related symptoms (21/23, 91%) was the most prevalent outcome, of which positive symptoms (13/23, 57%), mood and anxiety (10/23, 43%), and overall psychopathology severity (9/23, 39%) were most commonly measured. Patient-centric outcomes, including well-being (17/23, 74%)-particularly quality of life (10/23, 43%)-and user experience (15/23, 65%), including feasibility (7/23, 30%), acceptability (7/23, 30%), and engagement (7/23, 26%). Notably, outcome choices remained diverse despite stratification by type of mHealth intervention.

CONCLUSIONS

mHealth interventions for psychosis encompass a wide range of modalities and use outcome measures that probe various social and behavioral determinants of health. These should be considered complex interventions, and a holistic evaluation approach combining clinical and patient-centric outcomes is recommended.

Systematic review and meta-analysis of adverse events in clinical trials of mental health apps

Mental health apps are efficacious, yet they may pose risks in some. This review (CRD42024506486) examined adverse events (AEs) from mental health apps. We searched (May 2024) the Medline, PsycINFO, Web of Science, and ProQuest databases to identify clinical trials of mental health apps. The risk of bias was assessed using the Cochrane Risk of Bias tool. Only 55 of 171 identified clinical trials reported AEs. AEs were more likely to be reported in trials sampling schizophrenia and delivering apps with symptom monitoring technology. The meta-analytic deterioration rate from 13 app conditions was 6.7% (95% CI = 4.3, 10.1, I2 = 75%). Deterioration rates did not differ between app and control groups (OR = 0.79, 95% CI = 0.62-1.01, I2 = 0%). Reporting of AEs was heterogeneous, in terms of assessments used, events recorded, and detail provided. Overall, few clinical trials of mental health apps report AEs. Those that do often provide insufficient information to properly judge risks related to app use.

Digital AVATAR therapy for distressing voices in psychosis: the phase 2/3 AVATAR2 trial

Distressing voices are a core symptom of psychosis, for which existing treatments are currently suboptimal; as such, new effective treatments for distressing voices are needed. AVATAR therapy involves voice-hearers engaging in a series of facilitated dialogues with a digital embodiment of the distressing voice. This randomized phase 2/3 trial assesses the efficacy of two forms of AVATAR therapy, AVATAR-Brief (AV-BRF) and AVATAR-Extended (AV-EXT), both combined with treatment as usual (TAU) compared to TAU alone, and conducted an intention-to-treat analysis. We recruited 345 participants with psychosis; data were available for 300 participants (86.9%) at 16 weeks and 298 (86.4%) at 28 weeks. The primary outcome was voice-related distress at both time points, while voice severity and voice frequency were key secondary outcomes. Voice-related distress improved, compared with TAU, in both forms at 16 weeks but not at 28 weeks. Distress at 16 weeks was as follows: AV-BRF, effect -1.05 points, 96.5% confidence interval (CI) = -2.110 to 0, P = 0.035, Cohen's d = 0.38 (CI = 0 to 0.767); AV-EXT -1.60 points, 96.5% CI = -3.133 to -0.058, P = 0.029, Cohen's d = 0.58 (CI = 0.021 to 1.139). Distress at 28 weeks was: AV-BRF, -0.62 points, 96.5% CI = -1.912 to 0.679, P = 0.316, Cohen's d = 0.22 (CI = -0.247 to 0.695); AV-EXT -1.06 points, 96.5% CI = -2.700 to 0.586, P = 0.175, Cohen's d = 0.38 (CI = -0.213 to 0.981). Voice severity improved in both forms, compared with TAU, at 16 weeks but not at 28 weeks whereas frequency was reduced in AV-EXT but not in AV-BRF at both time points. There were no related serious adverse events. These findings provide partial support for our primary hypotheses. AV-EXT met our threshold for a clinically significant change, suggesting that future work should be primarily guided by this protocol. ISRCTN registration: ISRCTN55682735 .

Adverse Events Reporting in Digital Interventions Evaluations for Psychosis: A Systematic Literature Search and Individual Level Content Analysis of Adverse Event Reports

BACKGROUND

Digital health interventions (DHIs) have significant potential to upscale treatment access to people experiencing psychosis but raise questions around patient safety. Adverse event (AE) monitoring is used to identify, record, and manage safety issues in clinical trials, but little is known about the specific content and context contained within extant AE reports. This study aimed to assess current AE reporting in DHIs.

STUDY DESIGN

A systematic literature search was conducted by the iCharts network (representing academic, clinical, and experts by experience) to identify trials of DHIs in psychosis. Authors were invited to share AE reports recorded in their trials. A content analysis was conducted on the shared reports.

STUDY RESULTS

We identified 593 AE reports from 18 DHI evaluations, yielding 19 codes. Only 29 AEs (4.9% of total) were preidentified by those who shared AEs as being related to the intervention or trial procedures. While overall results support the safety of DHIs, DHIs were linked to mood problems and psychosis exacerbation in a few cases. Additionally, 27% of studies did not report information on relatedness for all or at least some AEs; 9.6% of AE reports were coded as unclear because it could not be determined what had happened to participants.

CONCLUSIONS

The results support the safety of DHIs, but AEs must be routinely monitored and evaluated according to best practice. Individual-level analyses of AEs have merit to understand safety in this emerging field. Recommendations for best practice reporting in future studies are provided.

Measurement of Adverse Events in Studies of Digital Health Interventions for Psychosis: Guidance and Recommendations Based on a Literature Search and Framework Analysis of Standard Operating Procedures

BACKGROUND

Given the rapid expansion of research into digital health interventions (DHIs) for severe mental illness (SMI; eg, schizophrenia and other psychosis diagnoses), there is an emergent need for clear safety measures. Currently, measurement and reporting of adverse events (AEs) are inconsistent across studies. Therefore, an international network, iCharts, was assembled to systematically identify and refine a set of standard operating procedures (SOPs) for AE reporting in DHI studies for SMI.

DESIGN

The iCharts network comprised experts on DHIs for SMI from seven countries (United Kingdom, Belgium, Germany, Pakistan, Australia, United States, and China) and various professional backgrounds. Following a literature search, SOPs of AEs were obtained from authors of relevant studies, and from grey literature.

RESULTS

A thorough framework analysis of SOPs (n = 32) identified commonalities for best practice for certain domains, along with significant gaps in others; particularly around the classification of AEs during trials, and the provision of training/supervision for research staff in measuring and reporting AEs. Several areas which could lead to the observed inconsistencies in AE reporting and handling were also identified.

CONCLUSIONS

The iCharts network developed best-practice guidelines and a practical resource for AE monitoring in DHI studies for psychosis, based on a systematic process which identified common features and evidence gaps. This work contributes to international efforts to standardize AE measurement and reporting in this emerging field, ensuring that safety aspects of DHIs for SMI are well-studied across the translational pathway, with monitoring systems set-up from the outset to support safe implementation in healthcare systems.

Leveraging Personal Technologies in the Treatment of Schizophrenia Spectrum Disorders: Scoping Review

BACKGROUND

Digital mental health is a rapidly growing field with an increasing evidence base due to its potential scalability and impacts on access to mental health care. Further, within underfunded service systems, leveraging personal technologies to deliver or support specialized service delivery has garnered attention as a feasible and cost-effective means of improving access. Digital health relevance has also improved as technology ownership in individuals with schizophrenia has improved and is comparable to that of the general population. However, less digital health research has been conducted in groups with schizophrenia spectrum disorders compared to other mental health conditions, and overall feasibility, efficacy, and clinical integration remain largely unknown.

OBJECTIVE

This review aims to describe the available literature investigating the use of personal technologies (ie, phone, computer, tablet, and wearables) to deliver or support specialized care for schizophrenia and examine opportunities and barriers to integrating this technology into care.

METHODS

Given the size of this review, we used scoping review methods. We searched 3 major databases with search teams related to schizophrenia spectrum disorders, various personal technologies, and intervention outcomes related to recovery. We included studies from the full spectrum of methodologies, from development papers to implementation trials. Methods and reporting follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

This search resulted in 999 studies, which, through review by at least 2 reviewers, included 92 publications. Included studies were published from 2010 to 2023. Most studies examined multitechnology interventions (40/92, 43%) or smartphone apps (25/92, 27%), followed by SMS text messaging (16/92, 17%) and internet-based interventions (11/92, 12%). No studies used wearable technology on its own to deliver an intervention. Regarding the stage of research in the field, the largest number of publications were pilot studies (32/92, 35%), followed by randomized control trials (RCTs; 20/92, 22%), secondary analyses (16/92, 17%), RCT protocols (16/92, 17%), development papers (5/92, 5%), and nonrandomized or quasi-experimental trials (3/92, 3%). Most studies did not report on safety indices (55/92, 60%) or privacy precautions (64/92, 70%). Included studies tend to report consistent positive user feedback regarding the usability, acceptability, and satisfaction with technology; however, engagement metrics are highly variable and report mixed outcomes. Furthermore, efficacy at both the pilot and RCT levels report mixed findings on primary outcomes.

CONCLUSIONS

Overall, the findings of this review highlight the discrepancy between the high levels of acceptability and usability of these digital interventions, mixed efficacy results, and difficulties with sustained engagement. The discussion highlights common patterns that may underscore this observation in the field; however, as this was a scoping review, a more in-depth systematic review or meta-analysis may be required to better understand the trends outlined in this review.

Efficacy of User Self-Led and Human-Supported Digital Health Interventions for People With Schizophrenia: A Systematic Review and Meta-Analysis

BACKGROUND

Digital health interventions (DHIs) may enable low cost, scalable improvements in the quality of care for adults with schizophrenia. Given the fast-growing number of studies using these tools, this review aimed to assess the efficacy and feasibility of randomized controlled trials (RCTs) of DHIs among people with schizophrenia, focusing on human support.

DESIGN

A systematic search of PubMed, Embase, PsycINFO, CINAHL, Web of Science, and Cochrane databases was conducted in January 2024 to identify relevant RCTs. Random effects meta-analyses were undertaken to evaluate the effects on psychosis symptoms, cognition, and other health-related outcomes.

RESULTS

Twenty-six RCTs (n = 2481 participants) were included. Pooled recruitment and retention rates were 57.4% and 87.6%, respectively. DHIs showed no statistically significant effect sizes across all examined outcomes, including psychosis symptoms, depression, quality of life, global and social cognition, global and social functioning, and medication adherence. A third (34.6%) of DHIs were developed using co-design while the majority (70%) personalized the intervention to its users and 69.2% were deemed to be at high risk of bias. There were trends toward effects in favor of DHIs with human support for social cognition and quality of life.

CONCLUSIONS

DHIs are feasible for people with schizophrenia and potentially useful for improving health outcomes, particularly when including human support. More high-quality studies are required to examine the benefits of human support within DHIs. Future research should examine the feasibility of sustained adherence and benefits from digital interventions, possibly incorporating human interaction complemented with artificial intelligence, in real-world clinical settings.

The role of human involvement and support in digital mental health interventions for people with schizophrenia spectrum disorders: a critical review

PURPOSE OF REVIEW

Schizophrenia spectrum disorders (SDD) are characterized by a complex array of psychosis symptoms, and typically require ongoing and long-term support, including pharmacological and nonpharmacological management. Digital mental health interventions (DMHIs) have been suggested as a novel therapeutic approach to enable low-cost, scalable improvements in quality of care for adults living with SSD. However, the types and role of human involvement and support within DMHIs is currently unknown.

RECENT FINDINGS

Several recent systematic reviews and meta-analyses have investigated the potential efficacy of DMHIs for people with SSD, with scant yet emerging systematic evidence on the effects of human support within DMHIs on mental health outcomes. Further, several recent individual studies examined the efficacy of DMHIs with human support among people with SSD and provided valuable insights into the potential key elements of such support on outcomes relevant to this population.

SUMMARY

The current critical review provides the first narrative synthesis of available evidence to guide clinicians and intervention develops in designing DMHIs with adequate human support that may enhance long-term outcomes of people living with SSD.

Family Empowerment Strategies for Relapse Prevention in Individuals With Schizophrenia: A Scoping Review

The current scoping review aimed to provide an overview of family empowerment strategies used in relapse prevention among individuals with schizophrenia. Three major topics were explored: (a) the family empowerment model used in relapse prevention among individuals with schizophrenia; (b) family intervention strategies; and (c) special considerations for integrating family empowerment in relapse prevention among individuals with schizophrenia. There is a need to identify and use family resources and strengths, such as acceptance of schizophrenia, development of spirituality, involvement in daily activities, and understanding of behaviors that exacerbate symptoms, to reduce relapse risk. The family empowerment paradigm incorporates new information and coping skills, family support, meaning-making, life objectives, self-reflection, and good family experiences. Families as agents of care at home should be provided with stress management and family psychoeducation to improve family resilience. Further research is needed to understand family empowerment and develop comprehensive guidelines regarding relapse prevention management among individuals with schizophrenia. [Journal of Psychosocial Nursing and Mental Health Services, 62(5), 19-27.].

Effectiveness of information technology assisted relapse prevention program on relapse among people who live with severe mental disorders

BACKGROUND

Severe Mental Disorders (SMDs) cause mental health worldwide challenges because of several relapses and extensive recovery periods of hospitalization, which put a lot of economic and social burden on families and governments. Therefore, interventions are necessary to decrease the relapse of these disorders.

AIM

This study was conducted to investigate the effect of Information Technology Assisted Relapse Prevention Program (ITAREP) on relapse among people who live with SMDs.

METHOD

This study was a randomized clinical trial with intervention and control groups. ITAREP is a remote intervention based on monitoring the Early Warning Signs (EWS) to decrease the number of potential relapses. Using convenience sampling, people with SMDs admitted to Sina Juneqan Psychiatric Hospital and their caregivers were recruited in this study and randomly allocated to the control and intervention groups. Two checklists of the EWS for the patient and the patient's caregiver were used for monitoring the relapse signs. Data were collected at baseline and 90 days after discharge and were analyzed using t-test and Chi-square statistical tests and linear regression in SPSS software.

RESULTS

Fifty-two patients who lived with SMDs participated in this study (26 in the intervention group and 26 in the control group). The two groups were homogeneous regarding age, gender, type of mental disorder, and duration of the disorder. Forty-two males and ten females participated in this research. Most of the participants were diagnosed with schizophrenia. The results showed that the number of relapses in the intervention group was significantly lower than in the control group in the post-test.

CONCLUSION

Social workers, as the case managers and a member of the interdisciplinary psychiatric team, can actively perform follow-up measures after discharge using ITAREP, and it can be expected that these interventions will reduce the number of relapses among patients who live with SMDs.

Acceptability and experience of a smartphone symptom monitoring app for people with psychosis in China (YouXin): a qualitative study

BACKGROUND

Access to high-quality mental healthcare remains challenging for people with psychosis globally, including China. Smartphone-based symptom monitoring has the potential to support scalable mental healthcare. However, no such tool, until now, has been developed and evaluated for people with psychosis in China. This study investigated the acceptability and the experience of using a symptom self-monitoring smartphone app (YouXin) specifically developed for people with psychosis in China.

METHODS

Semi-structured interviews were conducted with 10 participants with psychosis to explore the acceptability of YouXin. Participants were recruited from the non-randomised feasibility study that tested the validity, feasibility, acceptability and safety of the YouXin app. Data analysis was guided by the theoretical framework of acceptability.

RESULTS

Most participants felt the app was acceptable and easy to use, and no unbearable burdens or opportunity costs were reported. Participants found completing the self-monitoring app rewarding and experienced a sense of achievement. Privacy and data security were not major concerns for participants, largely due to trust in their treating hospital around data protection. Participants found the app easy to use and attributed this to the training provided at the beginning of the study. A few participants said they had built some form of relationship with the app and would miss the app when the study finished.

CONCLUSIONS

The YouXin app is acceptable for symptom self-monitoring in people with experience of psychosis in China. Participants gained greater insights about their symptoms by using the YouXin app. As we only collected retrospective acceptability in this study, future studies are warranted to assess hypothetical acceptability before the commencement of study to provide a more comprehensive understanding of implementation.

Speech markers to predict and prevent recurrent episodes of psychosis: A narrative overview and emerging opportunities

Preventing relapse in schizophrenia improves long-term health outcomes. Repeated episodes of psychotic symptoms shape the trajectory of this illness and can be a detriment to functional recovery. Despite early intervention programs, high relapse rates persist, calling for alternative approaches in relapse prevention. Predicting imminent relapse at an individual level is critical for effective intervention. While clinical profiles are often used to foresee relapse, they lack the specificity and sensitivity needed for timely prediction. Here, we review the use of speech through Natural Language Processing (NLP) to predict a recurrent psychotic episode. Recent advancements in NLP of speech have shown the ability to detect linguistic markers related to thought disorder and other language disruptions within 2-4 weeks preceding a relapse. This approach has shown to be able to capture individual speech patterns, showing promise in its use as a prediction tool. We outline current developments in remote monitoring for psychotic relapses, discuss the challenges and limitations and present the speech-NLP based approach as an alternative to detect relapses with sufficient accuracy, construct validity and lead time to generate clinical actions towards prevention.

Evaluating a smartphone-based symptom self-monitoring app for psychosis in China (YouXin): A non-randomised validity and feasibility study with a mixed-methods design

Background

Psychosis causes a significant burden globally, including in China, where limited mental health resources hinder access to care. Smartphone-based remote monitoring offers a promising solution. This study aimed to assess the validity, feasibility, acceptability, and safety of a symptom self-monitoring smartphone app, YouXin, for people with psychosis in China.

Methods

A pre-registered non-randomised validity and feasibility study with a mixed-methods design. Participants with psychosis were recruited from a major tertiary psychiatric hospital in Beijing, China. Participants utilised the YouXin app to self-monitor psychosis and mood symptoms for four weeks. Feasibility outcomes were recruitment, retention and outcome measures completeness. Active symptom monitoring (ASM) validity was tested against corresponding clinical assessments (PANSS and CDS) using Spearman correlation. Ten participants completed qualitative interviews at study end to explore acceptability of the app and trial procedures.

Results

Feasibility parameters were met. The target recruitment sample of 40 participants was met, with 82.5% completing outcome measures, 60% achieving acceptable ASM engagement (completing >33% of all prompts), and 33% recording sufficient passive monitoring data to extract mobility indicators. Five ASM domains (hallucinations, suspiciousness, guilt feelings, delusions, grandiosity) achieved moderate correlation with clinical assessment. Both quantitative and qualitative evaluation showed high acceptability of YouXin. Clinical measurements indicated no symptom and functional deterioration. No adverse events were reported, suggesting YouXin is safe to use in this clinical population.

Conclusions

The trial feasibility, acceptability and safety parameters were met and a powered efficacy study is indicated. However, refinements are needed to improve ASM validity and increase passive monitoring data completeness.

Behavioral marker-based predictive modeling of functional status for older adults with subjective cognitive decline and mild cognitive impairment: Study protocol

Objective

This study describes a research protocol for a behavioral marker-based predictive model that examines the functional status of older adults with subjective cognitive decline and mild cognitive impairment.

Methods

A total of 130 older adults aged ≥65 years with subjective cognitive decline or mild cognitive impairment will be recruited from the Dementia Relief Centers or the Community Service Centers. Data on behavioral and psychosocial markers (e.g. physical activity, mobility, sleep/wake patterns, social interaction, and mild behavioral impairment) will be collected using passive wearable actigraphy, in-person questionnaires, and smartphone-based ecological momentary assessments. Two follow-up assessments will be performed at 12 and 24 months after baseline. Mixed-effect machine learning models: MErf, MEgbm, MEmod, and MEctree, and standard machine learning models without random effects [random forest, gradient boosting machine] will be employed in our analyses to predict functional status over time.

Results

The results of this study will be fundamental for developing tailored digital interventions that apply deep learning techniques to behavioral data to predict, identify, and aid in the management of functional decline in older adults with subjective cognitive decline and mild cognitive impairment. These older adults are considered the optimal target population for preventive interventions and will benefit from such tailored strategies.

Conclusions

Our study will contribute to the development of self-care interventions that utilize behavioral data and machine learning techniques to provide automated analyses of the functional decline of older adults who are at risk for dementia.

A mixed-methods review and meta-synthesis of fears of recurrence and progression in people with mental health conditions

A fear that one's physical illness will recur or worsen has received substantial research attention over the past decade, most notably as fear of cancer recurrence. Indeed, such fear is known to be associated with poorer quality of life, adjustment, and psychopathology. However, fear of a recurrence or progression (FORP) of mental health conditions has received comparatively little study. The present review aimed to, 1) systematically review quantitative research on FORP in mental health regarding its association with age, gender, quality of life, mental health outcomes, and health behaviours, and 2) meta-synthesize qualitative research related to FORP to construct a transdiagnostic model. A qualitative meta-synthesis of 19 studies identified four subthemes underlying FORP (fear of symptoms, loss of progress, fear of death, and traumatic experiences). The three themes related to FORP were: inability to trust oneself, hypervigilance, and a low-risk low-reward lifestyle which was comprised of three subthemes (limiting relationships, limiting life goals, and fear of changing treatment). A quantitative systematic review of 15 studies found that FORP was strongly associated with worse quality of life, and greater depression, anxiety, psychotic symptoms, and medication adherence, but was not associated with age or gender. Hence, FORP can be understood transdiagnostically, and is generally associated with poorer mental health outcomes but may also predict adaptive health behaviours, such as appropriate medication adherence.

Digital tools to support mental health: a survey study in psychosis

BACKGROUND

There is a notable a gap between promising research findings and implementation of digital health tools. Understanding and addressing barriers to use is key to widespread implementation.

METHODS

A survey was administered to a self-selecting sample in-person (n = 157) or online (n = 58), with questions examining: i) ownership and usage rates of digital devices among people with psychosis; ii) interest in using technology to engage with mental health services; and iii) facilitators of and barriers to using digital tools in a mental healthcare context.

RESULTS

Device ownership: Virtually all participants owned a mobile phone (95%) or smartphone (90%), with Android phones slightly more prevalent than iPhones. Only a minority owned a fitness tracker (15%) or smartwatch (13%). Device ownership was significantly lower in unemployed people and those without secondary education. Device cost and paranoid ideation were barriers to ownership. Technology and mental health services: Most participants (88%) said they would willingly try a mental health app. Symptom monitoring apps were most popular, then appointment reminders and medication reminders. Half the sample would prefer an app alongside face-to-face support; the other half preferred remote support or no other mental health support. Facilitators: Participants thought using a mental health app could increase their understanding of psychosis generally, and of their own symptoms. They valued the flexibility of digital tools in enabling access to support anywhere, anytime. Barriers: Prominent barriers to using mental health apps were forgetting, lack of motivation, security concerns, and concerns it would replace face-to-face care. Overall participants reported no substantial effects of technology on their mental health, although a quarter said using a phone worsened paranoid ideation. A third used technology more when psychotic symptoms were higher, whereas a third used it less. Around half used technology more when experiencing low mood.

CONCLUSIONS

Our findings suggest rapidly increasing device ownership among people with psychosis, mirroring patterns in the general population. Smartphones appear appropriate for delivering internet-enabled support for psychosis. However, for a sub-group of people with psychosis, the sometimes complex interaction between technology and mental health may act as a barrier to engagement, alongside more prosaic factors such as forgetting.

Relapse prediction in schizophrenia with smartphone digital phenotyping during COVID-19: a prospective, three-site, two-country, longitudinal study

Smartphone technology provides us with a more convenient and less intrusive method of detecting changes in behavior and symptoms that typically precede schizophrenia relapse. To take advantage of the aforementioned, this study examines the feasibility of predicting schizophrenia relapse by identifying statistically significant anomalies in patient data gathered through mindLAMP, an open-source smartphone app. Participants, recruited in Boston, MA in the United States, and Bangalore and Bhopal in India, were invited to use mindLAMP for up to a year. The passive data (geolocation, accelerometer, and screen state), active data (surveys), and data quality metrics collected by the app were then retroactively fed into a relapse prediction model that utilizes anomaly detection. Overall, anomalies were 2.12 times more frequent in the month preceding a relapse and 2.78 times more frequent in the month preceding and following a relapse compared to intervals without relapses. The anomaly detection model incorporating passive data proved a better predictor of relapse than a naive model utilizing only survey data. These results demonstrate that relapse prediction models utilizing patient data gathered by a smartphone app can warn the clinician and patient of a potential schizophrenia relapse.

Exploring digital cognitive behavioural therapy for insomnia in an early intervention in psychosis service - A study protocol for an initial feasibility study with process evaluation

AIM

Early psychosis may be a critical time at which clinical trajectories are still evolving, and sleep interventions hold promise to improve outcomes at this stage. Although cognitive behavioural therapy (CBT) for insomnia shows promise in psychosis, there has been limited evaluation of delivery within current care. This study aims to evaluate the feasibility and acceptability of providing fully-automated digital CBT for insomnia (CBT-I) within an early intervention in psychosis service.

METHODS

We will conduct a single-arm feasibility trial within an early psychosis intervention service, and up to 40 individuals experiencing a first episode of psychosis and with evidence of insomnia can be enrolled (May 2021 - August 2022). Additional service user inclusion criteria are capacity to consent and access to a suitable technological device to access digital CBT. Participants will be offered access to a fully-automated digital CBT-I program (Sleepio) delivered using web and/or mobile app. The study comprises pre- and post- intervention questionnaire assessments and interviews with service users and staff to provide initial outcome signals.

RESULTS

Quantitative questionnaire data will be analysed descriptively, alongside rates of eligibility, consent, uptake and completion. Qualitative data will be analysed using thematic analysis. Results will be used to develop a logic model describing feasibility and implementation.

CONCLUSIONS

From this study, we hope to better understand how to deliver digital CBT for insomnia within an early intervention in psychosis service. This study will help inform further research, including how best to support staff in using Sleepio, and inform the design of subsequent trials in this area.