A Clinical Trial to Test the Feasibility of a Telehealth Psychoeducational Intervention for Persons With Schizophrenia and Their Families: Intervention and 3-Month Findings

Perspective of patients with first-episode psychosis, their relatives, and mental health professionals on the design and usability of an app in clinical practice

AIM

Therapeutic non-compliance remains the main difficulty for people with psychotic disorders, standing around 50% in people with schizophrenia. Lack of treatment adherence, either partial or total, to medication has economic and clinical consequences. E-health technologies may be a promising therapeutic tool to improve adherence, with the subsequent reduction in clinical and economic burden. Our aims were to know the preferences on how technologies in mental health treatment should be for use in clinical practice, and to learn about the opinion and preferences on the use of technologies in mental health treatment from the perspectives of patients with FEP, their relatives, and mental health professionals.

METHODS

Forty-one patients with a diagnosis of first-episode psychosis (FEP), 18 relatives and 49 mental health professionals were included in the study. They completed an online survey related to the use, availability and user-skill of online platforms and apps created by a group of experts in psychosis and in the use of technologies. Data were summarized in frequencies, percentages, and means, and Chi-square tests were used to calculate differences between-groups.

RESULTS

An app directed to people with psychosis would be well received by users if it contains psychoeducational material, offers reminders for scheduled visits and treatment and allows online consultations.

CONCLUSIONS

Co-creating an app with users, their families and mental health professionals allows incorporating their preferences to increase its use, improve outpatient care and creating an app that is viable in clinical practice.

Through COVID-19 and beyond: developing a multidisciplinary telehealth family intervention in first episode psychosis

The COVID-19 pandemic presents unique challenges to high quality, safe Early Intervention in Psychosis (EIP) service provision. Due to the necessity to ensure EIP continues despite this, we developed a multidisciplinary, blended, telehealth intervention, incorporating psychoeducation and peer support, for family members of first episode psychosis service users: PERCEPTION. This perspective article aims to: describe PERCEPTION; offer reflections on our experience of delivering it; make recommendations for future research; and synthesise key learning to assist the integration of similar interventions in other EIP services. We provide a descriptive account of PERCEPTION's development and implementation, with reflections from the clinicians involved, on supporting families using this approach. We experienced telehealth as patient-focused, safe, and efficient and believe the intervention's blended nature augmented families' engagement. The approach adopted can assist service providers to attain balance between protecting public health and offering a meaningful, therapeutic intervention to support families in the current epoch.

Efficacy of Remotely Delivered Evidence-Based Psychosocial Treatments for Schizophrenia-Spectrum Disorders: A Series of Systematic Reviews and Meta-Analyses

BACKGROUND

Schizophrenia is among the most persistent and debilitating mental health conditions worldwide. The American Psychological Association (APA) has identified 10 psychosocial treatments with evidence for treating schizophrenia and these treatments are typically provided in person. However, in-person services can be challenging to access for people living in remote geographic locations. Remote treatment delivery is an important option to increase access to services; however, it is unclear whether evidence-based treatments for schizophrenia are similarly effective when delivered remotely.

STUDY DESIGN

The current study consists of a series of systematic reviews and meta-analyses examining the evidence-base for remote-delivery of each of the 10 APA evidence-based treatments for schizophrenia.

RESULTS

Of the 10 treatments examined, only cognitive remediation (CR), cognitive-behavioral therapy (CBT), and family psychoeducation had more than 2 studies examining their efficacy for remote delivery. Remote delivery of CBT produced moderate effects on symptoms (g = 0.43) and small effects on functioning (g = 0.26). Remote delivery of CR produced small-moderate effects on neurocognition (g = 0.35) and small effects on functioning (g = 0.21). There were insufficient studies of family psychoeducation with equivalent outcome measures to assess quantitatively, however, studies of remotely delivered family psychoeducation suggested that it is feasible, acceptable, and potentially effective.

CONCLUSIONS

Overall, the evidence-base for remotely delivered treatment for schizophrenia is limited. Studies to date suggest that remote adaptations may be effective; however, more rigorous trials are needed to assess efficacy and methods of remote delivery that are most effective.

Operationalising a Recovery-Oriented Support and Information Programme Online: The EOLAS Programme

Evidence demonstrates that psychoeducation interventions have clinical and recovery-related benefits for people experiencing psychosis and their family members. The EOLAS programmes are one example of recovery-oriented psychoeducation programmes for psychosis. They differ from other programmes in that they are co-designed and co-facilitated (peer and clinician) group programmes. Due to the COVID-19 pandemic, EOLAS went online using a videoconferencing platform. The study examined the feasibility, acceptability and usefulness of EOLAS-Online and explored whether some of the positive recovery outcomes reported by attendees regarding the in-person programmes were replicated online. Data were collected through an online survey and semi-structured interviews. Quantitative data were analysed using descriptive statistics. Thematic analysis was used for qualitative data. Fifteen attendees (40% of attendees) completed the surveys and eight participated in interviews. A total of 80% were satisfied/very satisfied with the programme. The programme was rated highly for increased knowledge of mental health, coping strategies, and engaging with peers. The use of technology was mostly unproblematic, although some audio and video-related challenges were identified. Engaging with the online programme was experienced positively, including facilitator support to engage. The overall findings indicate that EOLAS-Online is feasible, acceptable and useful in supporting attendees' recovery journeys.

An Update of Peer Support/Peer Provided Services Underlying Processes, Benefits, and Critical Ingredients

The purpose of this article is to delineate the current state-of-the-knowledge of peer support following the framework employed in the 2004 article (Solomon, Psychiatr Rehabil J. 2004;27(4):392-401 1). A scoping literature was conducted and included articles from 1980 to present. Since 2004, major growth and advancements in peer support have occurred from the development of new specializations to training, certification, reimbursement mechanisms, competency standards and fidelity assessment. Peer support is now a service offered across the world and considered an indispensable mental health service. As the field continues to evolve and develop, peer support is emerging as a standard of practice throughout various, diverse settings and shows potential to impact clinical outcomes for service users throughout the globe. While these efforts have enhanced the professionalism of the peer workforce, hopefully this has enhanced the positive elements of these services and not diluted them.

Digital interventions for subjective and objective social isolation among individuals with mental health conditions: a scoping review

BACKGROUND

Social isolation encompasses subjective and objective concepts. Both are associated with negative health consequences and are more prevalent among people with mental health problems than among the general population. To alleviate social isolation, digital interventions have potential as accessible alternatives or adjuncts to face-to-face interventions. This scoping review aimed to describe the types of digital interventions evaluated for feasibility, acceptability and effectiveness in alleviating social isolation among individuals with mental health problems, and to present an overview of the quantitative evidence yielded to inform future intervention design.

METHODS

We searched five electronic databases for quantitative and mixed methods studies published between January 2000 and July 2020. Studies were included if they evaluated digital interventions for individuals with mental health conditions, had subjective and/or objective social isolation as their primary outcome, or as one of their outcomes if no primary outcome was specified. Feasibility studies were included if feasibility outcomes were the primary outcomes and social isolation was among their secondary outcomes. A narrative synthesis was conducted to present our findings. The protocol was registered on Open Science Framework (doi: https://doi.org/10.17605/OSF.IO/CNX8A ).

RESULTS

Thirty-two studies were included for our review: 16 feasibility studies, seven single-group studies and nine effectiveness trials. There was great variation in the interventions, study designs and sample populations. Interventions included web-based programmes, phone-based programmes, blended interventions, socially assistive robots and virtual reality interventions. Many were feasibility studies, or otherwise not fully powered to detect an effect if one were present, thus preventing clear conclusions about clinical effectiveness. Satisfactory feasibility outcomes indicated potential for future trials to assess these interventions.

CONCLUSION

Our scoping review identified a range of digital approaches utilized to alleviate social isolation among individuals with mental health disorders. Conclusions regarding clinical effectiveness cannot be reached due to variability of approaches and lack of large-scale randomized controlled trials. To make clear recommendations for digital social isolation interventions, future research needs to be based on rigorous methods and larger samples. Future studies should also focus on utilizing theory-driven approaches and improving existing approaches to advance the field.

Telehealth-Based Psychoeducation for Caregivers: The Family Intervention in Recent-Onset Schizophrenia Treatment Study

BACKGROUND

Schizophrenia is a lifelong illness that requires long-term treatment and caregiving. Family psychoeducation (FP) has been shown to lessen caregiver burden, improve caregiver functioning, and improve outcomes in patients. However, the impact of FP delivered specifically to caregivers on patient outcomes has not been well explored, particularly for early schizophrenia. Furthermore, there is a lack of research examining the benefits of telehealth-based psychoeducation for caregivers on either patient or caregiver outcomes.

OBJECTIVE

The Family Intervention in Recent-Onset Schizophrenia Treatment (FIRST) study is a randomized controlled trial of patients with schizophrenia spectrum disorders and their caregivers, which is designed to evaluate the effect of telehealth-based, caregiver-focused, study-provided psychoeducation versus usual care (UC) on patient treatment failure (TF). The impact of study-provided psychoeducation on caregiver burden is also investigated.

METHODS

Eligible patients and their designated caregivers were randomly assigned to either the study-provided psychoeducation (≤16 sessions of telehealth-based psychoeducation over 6 months) or UC group, stratified by antipsychotic treatment (paliperidone palmitate or oral antipsychotic). The major TF events (ie, psychiatric hospitalization or intervention, arrest or incarceration, and suicide attempts) were assessed at 3, 6, and 12 months after baseline. A proportional means model using mean cumulative function was used to assess between-group differences in the mean cumulative number of TF events over 12 months. Caregiver burden was assessed using the Involvement Evaluation Questionnaire and 12-item Short Form Health Survey.

RESULTS

A total of 148 pairs of participants were enrolled in the study, of whom 96 (64.9%) patients and 94 (63.5%) caregivers completed the 12-month follow-up. The mean number of sessions in the study-provided psychoeducation group was 7.7 (SD 5.9). No differences were observed between the study-provided psychoeducation and UC groups in patient outcomes (rates of TF: 70% vs 67%; P=.90) or measures of caregiver burden (assessment of caregiver distress and physical and mental health). However, post hoc analyses revealed lower relapse rates in patients who received paliperidone palmitate than in those who received oral antipsychotics at all time points. Although the FIRST study did not meet the primary end point, several key lessons were identified to inform future caregiver-focused, telehealth-based FP interventions. Lack of study-provided psychoeducation, focus on caregiver-only intervention, difficulties with enrollment, and caregiver-treatment team coordination may have affected the outcomes of the FIRST study.

CONCLUSIONS

Key insights from the FIRST study suggest the potential importance of supporting sufficient caregiver engagement; communication between clinicians, patients, and family members regarding treatment plans; and solidifying the relationship between clinicians providing psychoeducation to the caregiver and patient treatment team.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02600741; http://clinicaltrials.gov/ct2/show/NCT02600741.

A web-based, peer-supported self-management intervention to reduce distress in relatives of people with psychosis or bipolar disorder: the REACT RCT

BACKGROUND

Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution.

OBJECTIVE

The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives' Education And Coping Toolkit (REACT).

DESIGN AND SETTING

This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks.

PARTICIPANTS

A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited.

INTERVENTION

REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages.

MAIN OUTCOME MEASURE

The main outcome was the level of participants' distress, as measured by the General Health Questionnaire-28 items.

RESULTS

Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference -1.39, 95% confidence interval -3.60 to 0.83; p = 0.22). At 12 weeks, the General Health Questionnaire-28 items scores were lower in the REACT arm than in the resource directory-only arm (-2.08, 95% confidence interval -4.14 to -0.03; p = 0.027), but this finding is likely to be of limited clinical significance. Accounting for missing data, which were associated with higher distress in the REACT arm (0.33, 95% confidence interval -0.27 to 0.93; p = 0.279), in a longitudinal model, there was no significant difference between arms over 24 weeks (-0.56, 95% confidence interval -2.34 to 1.22; p = 0.51). REACT cost £142.95 per participant to design and deliver (£62.27 for delivery only), compared with £0.84 for the resource directory only. A health economic analysis of NHS, health and Personal Social Services outcomes found that REACT has higher costs (£286.77), slightly better General Health Questionnaire-28 items scores (incremental General Health Questionnaire-28 items score adjusted for baseline, age and gender: -1.152, 95% confidence interval -3.370 to 1.065) and slightly lower quality-adjusted life-year gains than the resource directory only; none of these differences was statistically significant. The median time spent online was 50.8 minutes (interquartile range 12.4-172.1 minutes) for REACT, with no significant association with outcome. Participants reported finding REACT a safe, confidential environment (96%) and reported feeling supported by the forum (89%) and the REACT supporters (86%). No serious adverse events were reported.

LIMITATIONS

The sample comprised predominantly white British females, 25% of participants were lost to follow-up and dropout in the REACT arm was not random.

CONCLUSIONS

An online self-management support toolkit with a moderated group forum is acceptable to relatives and, compared with face-to-face programmes, offers inexpensive, safe delivery of National Institute for Health and Care Excellence-recommended support to engage relatives as peers in care delivery. However, currently, REACT plus the resource directory is no more effective at reducing relatives' distress than the resource directory only.

FUTURE WORK

Further research in improving the effectiveness of online carer support interventions is required.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN72019945.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 32. See the NIHR Journals Library website for further project information.

Mobile Health for Caregivers of Young Adults With Early Psychosis: A Survey Study Examining User Preferences

OBJECTIVE

Caregivers play a key role in supporting the recovery of young adults with early psychosis. This role often involves considerable responsibilities and burden. Despite the considerable needs of caregivers, troubling service gaps addressing these needs remain. Digital technologies may increase caregivers' access to supportive resources; however, technologies developed specifically for caregivers lag far behind those developed for their relatives affected by early psychosis. In particular, little is known about the mobile health (mHealth) features that may be most acceptable to caregivers.

METHODS

The authors surveyed a sample of 43 caregivers on their interests regarding various features of a proposed mHealth intervention.

RESULTS

Caregivers of young adults with early psychosis were highly interested in a caregiver-facing mHealth intervention, specifically one providing information about psychosis, treatments, and communication with their affected family member.

CONCLUSIONS

Future caregiver-focused mHealth intervention interventions may be highly acceptable to this population and may address pressing service gaps.

Feasibility of a Web-Based Psychoeducation Course and Experiences of Caregivers Living With a Person With Schizophrenia Spectrum Disorder: Mixed Methods Study

BACKGROUND

Schizophrenia is a severe mental illness that burdens both patients and caregivers.

OBJECTIVE

The aim of this study is to examine the feasibility of a web-based psychoeducation course targeted at caregivers of persons with schizophrenia spectrum disorders (SSDs) and to describe their experiences of living with a person with SSD based on the material caregivers produced during the web-based course.

METHODS

A convergent, parallel, mixed methods study design was used. First, caregivers' engagement in the course was evaluated quantitatively. Second, the overview of the course feedback was evaluated using quantitative and qualitative methods. Third, the experiences of being a caregiver to a person with SSD were analyzed qualitatively with the thematic analysis of the writings caregivers produced during the web-based course.

RESULTS

A total of 30 caregivers participated in the study and a web-based psychoeducation course. Less than two-thirds (18/30, 60%) completed the course. Content was most often logged for the first module, Orientation (3465 log-ins), and the lowest number of log-ins was recorded for the Daily life module (1061 log-ins). Feedback on the course varied; over half (10/17, 59%) of the caregivers considered the content to be very good or good, about half (9/17, 53%) considered the website layout to be good, only 6% (1/17) felt that the usability of the website was poor, and no one felt that it was very poor. From the reported experiences of being a caregiver to a person with SSD, 3 themes were formed: the caregiver's own well-being, relationship with the person with SSD, and experience of health care services.

CONCLUSIONS

The web-based psychoeducation course for caregivers living with a person with SSD seems to be especially suitable for those who have little experience as a caregiver. In the future, more planning and the consideration of aspects related to the needs of specific target groups, course content, practical arrangements, and scheduling should be taken into account. In addition, although caregivers can improve their own well-being in different ways, they need regular support and cooperation from health care professionals.

Exploring the Efficacy of Telehealth for Family Therapy Through Systematic, Meta-analytic, and Qualitative Evidence

There is a current escalating need for telehealth (TH) options in family mental health services. In the absence of replicated evidence, TH guidelines from peak bodies are largely based on assumptions of the effectiveness of TH methods. New investments in TH would optimally be based in evidence of clinical efficacy. To this end, we conducted three studies in which we (1) systematically reviewed eight professional guidelines for TH family therapy, (2) examined replicated evidence for the efficacy of TH family therapy through systematic review of 20 studies and meta-analyses of 13 effects, and (3) synthesised clinical accommodations to TH methodology from a study of 12 experienced TH family therapists. The studies found (1) a predominant focus in existing TH guidelines on operational matters pertaining to TH and relative neglect of therapeutic process; (2) meta-analyses of efficacy for child behavioural problems (k = 8) and parental depression (k = 5) showed equivalent outcomes in TH and face-to-face therapy and enhanced outcomes in TH relative to treatment as usual, resource provision (i.e. written materials), or wait-list control. Narrative review of 20 studies for a range of relational and mental health outcomes aligned with these findings; and (3) therapists defined clear conditions for enhanced engagement and therapeutic process via TH and reflected on cautions and accommodations for purposes of rapport building and mitigating risk. Given moderate-strong evidence for the efficacy of TH methods of family therapy for a range of conditions, we offer recommendations for future implementation of TH for family therapy.

Facilitating pathways to care: A qualitative study of the self-reported needs and coping skills of caregivers of young adults diagnosed with early psychosis

WHAT IS KNOWN ON THE SUBJECT?: In clinical psychiatry and mental health nursing practice, family caregivers are known to provide the bulk of care and play an important role in facilitating recovery outcomes for their loved ones diagnosed with psychosis. Providing services and interventions to family caregivers is as important as to patients in the early stage of psychotic experience for having a beneficial impact on the patients' clinical and social outcomes. Limited qualitative research has focused on family caregivers' subjective views of what they need during the critical period to identify early warning signs and connect their loved ones to professional help as they have no prior experience in caring for persons with psychosis. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Using qualitative analysis of family caregiver focus groups, this manuscript provides readers in clinical nursing practice with an understanding of family caregivers' lived experiences of supporting their loved one diagnosed with early psychosis. Understanding family caregivers' caregiving unmet needs in supporting their loved one diagnosed with early psychosis could inform both the technology-assisted intervention development and nursing practice in improving family-centred care and facilitate self-management practice. IMPLICATIONS FOR MENTAL HEALTH NURSING: Psychiatry and mental health nursing has long been engaged with the health and well-being of individuals with psychosis and supporting their families in the development, evaluation and implementation of innovative approaches to patient and family education. Digital technologies designed to deliver tailored intervention for family caregivers are underdeveloped, and the present study identifies a number of potential features that could comprise technology to meet the needs of this population. ABSTRACT: Introduction Caregivers play a critical role in detecting and managing psychotic symptoms before young people diagnosed with early psychosis present to care. Little is known about the specific needs of caregivers in navigating pathways to care for their loved one. Aim The purpose of this study was to understand the needs of family caregivers and their ways of coping on the pathway to care for early psychosis. Method Twenty family caregivers of individuals diagnosed with early psychosis participated in three focus groups that explored caregiving needs provision for early psychosis. Thematic analysis was conducted. Results We identified four major themes: education and skill training; raising wider awareness, such as police offers and teachers; adopting technologies for coping; and effective coping strategies. Implications for practice These findings provide important insights into caregiving needs and the ways for nurses to address those needs and better equip carers to recognize early symptoms, monitor behaviour changes and navigate care to support people with first-episode psychosis. Nursing researchers can use the information to develop on-demand and tailored family-centred intervention in addressing caregivers' needs in education, increasing awareness of early psychosis and fostering effective coping strategies.

The effectiveness of interventions for reducing subjective and objective social isolation among people with mental health problems: a systematic review

PURPOSE

Subjective and objective social isolation are important factors contributing to both physical and mental health problems, including premature mortality and depression. This systematic review evaluated the current evidence for the effectiveness of interventions to improve subjective and/or objective social isolation for people with mental health problems. Primary outcomes of interest included loneliness, perceived social support, and objective social isolation.

METHODS

Three databases were searched for relevant randomised controlled trials (RCTs). Studies were included if they evaluated interventions for people with mental health problems and had objective and/or subjective social isolation (including loneliness) as their primary outcome, or as one of a number of outcomes with none identified as primary.

RESULTS

In total, 30 RCTs met the review's inclusion criteria: 15 included subjective social isolation as an outcome and 11 included objective social isolation. The remaining four evaluated both outcomes. There was considerable variability between trials in types of intervention and participants' characteristics. Significant results were reported in a minority of trials, but methodological limitations, such as small sample size, restricted conclusions from many studies.

CONCLUSION

The evidence is not yet strong enough to make specific recommendations for practice. Preliminary evidence suggests that promising interventions may include cognitive modification for subjective social isolation, and interventions with mixed strategies and supported socialisation for objective social isolation. We highlight the need for more thorough, theory-driven intervention development and for well-designed and adequately powered RCTs.

Digital Peer Support Mental Health Interventions for People With a Lived Experience of a Serious Mental Illness: Systematic Review

BACKGROUND

Peer support is recognized globally as an essential recovery service for people with mental health conditions. With the influx of digital mental health services changing the way mental health care is delivered, peer supporters are increasingly using technology to deliver peer support. In light of these technological advances, there is a need to review and synthesize the emergent evidence for peer-supported digital health interventions for adults with mental health conditions.

OBJECTIVE

The aim of this study was to identify and review the evidence of digital peer support interventions for people with a lived experience of a serious mental illness.

METHODS

This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) procedures. The PubMed, Embase, Web of Science, Cochrane Central, CINAHL, and PsycINFO databases were searched for peer-reviewed articles published between 1946 and December 2018 that examined digital peer support interventions for people with a lived experience of a serious mental illness. Additional articles were found by searching the reference lists from the 27 articles that met the inclusion criteria and a Google Scholar search in June 2019. Participants, interventions, comparisons, outcomes, and study design (PICOS) criteria were used to assess study eligibility. Two authors independently screened titles and abstracts, and reviewed all full-text articles meeting the inclusion criteria. Discrepancies were discussed and resolved. All included studies were assessed for methodological quality using the Methodological Quality Rating Scale.

RESULTS

A total of 30 studies (11 randomized controlled trials, 2 quasiexperimental, 15 pre-post designs, and 2 qualitative studies) were included that reported on 24 interventions. Most of the studies demonstrated feasibility, acceptability, and preliminary effectiveness of peer-to-peer networks, peer-delivered interventions supported with technology, and use of asynchronous and synchronous technologies.

CONCLUSIONS

Digital peer support interventions appear to be feasible and acceptable, with strong potential for clinical effectiveness. However, the field is in the early stages of development and requires well-powered efficacy and clinical effectiveness trials.

TRIAL REGISTRATION

PROSPERO CRD42020139037; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID= 139037.

Dyadic Psychosocial eHealth Interventions: Systematic Scoping Review

Background

Dyadic psychosocial interventions have been found beneficial both for people coping with mental or physical health conditions as well as their family members and friends who provide them with support. Delivering these interventions via electronic health (eHealth) may help increase their scalability.

Objective

This scoping review aimed to provide the first comprehensive overview of dyadic eHealth interventions for individuals of all ages affected by mental or physical illness and their family members or friends who support them. The goal was to understand how dyadic eHealth interventions have been used and to highlight areas of research needed to advance dyadic eHealth intervention development and dissemination.

Methods

A comprehensive electronic literature search of PubMed, EMBASE, Cochrane, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO was conducted for articles published in the English language through March 2019. Eligible records described a psychosocial eHealth intervention that intervened with both care recipients and their support person.

Results

A total of 7113 records were reviewed of which 101 met eligibility criteria. There were 52 unique dyadic eHealth interventions identified, which were tested across 73 different trials. Of the unique interventions, 33 were conducted among dyads of children and their supporting parent, 1 was conducted with an adolescent-young adult care recipient population, and the remaining 18 were conducted among adult dyads. Interventions targeting pediatric dyads most commonly addressed a mental health condition (n=10); interventions targeting adult dyads most commonly addressed cancer (n=9). More than three-fourths of interventions (n=40) required some human support from research staff or clinicians. Most studies (n=64) specified one or more primary outcomes for care recipients, whereas less than one-fourth (n=22) specified primary outcomes for support persons. Where specified, primary outcomes were most commonly self-reported psychosocial or health factors for both care recipients (n=43) and support persons (n=18). Results of the dyadic eHealth intervention tended to be positive for care recipients, but evidence of effects for support persons was limited because of few studies specifying primary outcomes for supporters. Trials of dyadic eHealth interventions were most commonly randomized controlled trials (RCTs; n=44), and RCTs most commonly compared the dyadic eHealth intervention to usual care alone (n=22).

Conclusions

This first comprehensive review of dyadic eHealth interventions demonstrates that there is substantial, diverse, and growing literature supporting this interventional approach. However, several significant gaps were identified. Few studies were designed to evaluate the unique effects of dyadic interventions relative to individual interventions. There was also limited assessment and reporting of outcomes for support persons, and there were no interventions meeting our eligibility criteria specifically targeting the needs of older adult dyads. Findings highlight areas of research opportunities for developing dyadic eHealth interventions for novel populations and for increasing access to dyadic care.

A systematic review of online interventions for families of patients with severe mental disorders

BACKGROUND

Several studies show the effectiveness of face-to-face interventions with families in improving the prognosis of patients with severe psychiatric disorders and their relatives; however, the effectiveness of online interventions is poorly understood. The current study aims to provide an overview of evidence for the effectiveness of online treatments (web/app) for patients with severe psychiatric disorders and their families.

METHOD

We performed a systematic review of online treatments for informal family caregivers of patients with a severe psychiatric disorder. The study psychological interventions had to have been administered in an exclusively online format (app, internet) and aimed at families of patients with severe mental disorder (at least one of first episode psychosis, schizophrenia, schizoaffective, bipolar disorder, and psychotic disorder).

RESULTS

Of a total of 1331 articles, we identified 9 viable studies; 4 randomized clinical trials, and 5 nonrandomized clinical studies. The present study is the first systematic review in this area. Online interventions were well accepted, with good adherence and satisfaction among the caregivers and patients and improved the symptoms of both caregivers and patients.

LIMITATIONS

Clinical and methodological diversity of the studies.

CONCLUSIONS

Burden improved, and perceived stress decreased in families. Moreover, the severity of positive symptoms decreased and fewer hospitalizations were recorded in patients than in the control group. Therefore, online interventions are a promising therapeutic approach for patients with severe mental disorder and their families. However, more studies-particularly randomized clinical trials-are needed in this area.

Preferences for family involvement among veterans in treatment for schizophrenia

OBJECTIVE

Examine preferences for family involvement in psychiatric care in a large, representative sample of veterans in treatment for schizophrenia.

METHOD

Veterans with schizophrenia or schizoaffective disorder (N = 801) completed an assessment that included questions about demographic and clinical characteristics, status of family support, and preference for family involvement in their psychiatric care. Open-ended items were independently coded by two raters and categorized; Cohen's kappa was calculated for each category.

RESULTS

Among the 801 participants, 496 (61.9%) indicated that they had a family member who provided them with regular support; 304 (37.9%) had no family member who provided support; and 1 did not respond. Among the 304 without support, 272 (89.4%) had a living family member. Of the 496 participants who had a supportive family member, 135 (27.2%) wanted their family member involved in their care. Of the 272 participants who did not have a supportive family member, but had living family, 57 (21.0%) wanted their family involved. Barriers to involvement included concerns about privacy and burden. Preferred method of involvement included contact with the patient's psychiatrist and education about the illness.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Preferences indicated by this large representative sample of individuals in care for schizophrenia indicate that a majority have supportive family and a substantial minority want family involved in their psychiatric care. Clinicians can address concerns about privacy and burden and deliver preferred services by phone or mail, overcoming anticipated barriers. Desire for family support groups was limited but present. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Usability evaluation of an eHealth intervention for family carers of individuals affected by psychosis: A mixed-method study

Background

Existing research suggests that eHealth interventions targeting family carers of individuals with long-term illness offer a promising approach to care delivery. In particular, digital psychoeducational interventions with interactive psychosocial support are well-received with high rates of satisfaction and acceptability. However, development of such interventions for psychosis carers is lacking. We developed a multi-component eHealth intervention specifically for carers of individuals affected by psychosis, called COPe-support (Carers fOr People with Psychosis e-support).

Objective

Using mixed methods to evaluate usability, system heuristics and perceived acceptability, we conducted a usability study to establish the suitability of the intervention prototype for the target user group.

Methods

Twenty-three carers were recruited to the study and participated in a think-aloud test or a remote online trial of the intervention. Qualitative feedback, post-use System Usability Scale (SUS) scores, and real-world usage data collected from the tests were analysed. These were also supplemented with heuristic evaluation data provided by an independent eLearning technology expert.

Results

Participants evaluated the intervention content as useful and helpful, and indicated that the system had satisfactory usability with a mean SUS score of 73%, above the usability quality benchmark threshold. Study results identified some minor usability issues, which were corroborated with the eLearning expert’s heuristic evaluation findings. We used these results to refine the COPe-support intervention.

Conclusions

The usability study with end-users and service providers identified real-life usage and usability issues. The study results helped us refine COPe-support and its delivery strategy before its launch as part of a large-scale clinical trial.

A Multicomponent eHealth Intervention for Family Carers for People Affected by Psychosis: A Coproduced Design and Build Study

Background

Psychosis, including schizophrenia, is the most common severe mental illness affecting 1% of the population worldwide. A large number of people provide long-term support and care for a relative with psychosis. Although psychoeducational interventions, especially those delivered through a face-to-face group format, have an established evidence base for improving the caregiving experience, well-being, and health outcomes, large-scale implementation and access remain limited. There is a demand for such provision to be made through the internet for greater flexibility and wider access.

Objective

This study aimed to integrate participatory research methodologies by the public, patients, and carers into the eHealth (electronic health) intervention design and build process to improve the product’s usability and acceptability.

Methods

We adapted a structured eHealth intervention build method to include participatory research activities involving key stakeholders and end users to co-design and coproduce our intervention. An expert advisory group (EAG) comprising public involvement members led the formative design and build work using an agile build process. Carers independent from the study were consulted on the evolving drafts of the intervention prototype through focus group meetings. These results were fed back into the intervention build work continuously to ensure end users’ input inform every stage of the process.

Results

An EAG comprising individuals with lived experience of psychosis, carers, health care professionals, researchers, voluntary organization workers, and eLearning experts (n=14) was established. A total of 4 coproduction workshops were held over 1 year during which the alpha and beta prototypes were designed and built through the participatory research work. Alongside this, 2 rounds of focus group study with carers (n=24, in 4 groups) were conducted to seek consultation on end users’ views and ideas to optimize the intervention design and usability. Finally, the EAG carried out a Web-based walk-through exercise on the intervention prototype and further refined it to make it ready for an online usability test. The final product contains multiple sections providing information on psychosis and related caregiving topics and interactive discussion forums with experts and peers for psychosocial support. It provides psychoeducation and psychosocial support for carers through the internet, promoting flexible access and individualized choices of information and support.

Conclusions

The participatory research work led to the coproduction of a eHealth intervention called COPe-support (Carers fOr People with Psychosis e-support). We believe the study methodology, results, and output have optimized the intervention design and usability, fitting the end users’ needs and usage pattern. COPe-support is currently being tested for its effectiveness in promoting carers’ health outcome through an online randomized controlled trial.

Trial Registration

ISRCTN Registry ISRCTN89563420; http://www.isrctn.com/ISRCTN89563420

Internet-Based Interventions for Carers of Individuals With Psychiatric Disorders, Neurological Disorders, or Brain Injuries: Systematic Review

BACKGROUND

Nonprofessional carers who provide support to an individual with a psychiatric or neurological disorder will often themselves experience symptoms of stress, anxiety, or low mood, and they perceive that they receive little support. Internet-based interventions have previously been found to be effective in the prevention and treatment of a range of mental health difficulties in carers.

OBJECTIVE

This review seeks to establish the status of internet-based interventions for informal (nonprofessional) carers of people with psychiatric or neurological disorders by investigating (1) the number and quality of studies evaluating the efficacy or effectiveness of internet-based carer interventions and (2) the impact that such interventions have on carer mental health, as well as (3) how internet-based interventions compare with other intervention types (eg, face-to-face treatment).

METHODS

A systematic literature search was conducted in January 2019 using the EMBASE (1974-present), Ovid MEDLINE (1946-present), PsychARTICLES, PsychINFO (1806-present), and Global Health (1973-present) databases, via the Ovid Technologies database. Search terms included carer, caregiver, online, technology, internet-based, internet, interactive, intervention, and evaluation. Studies selected for inclusion in this review met the following predetermined criteria: (1) delivering an intervention aimed primarily at informal carers, (2) carers supporting individuals with psychiatric disorders, stroke, dementia, or brain injury, (3) the intervention delivered to the carers was primarily internet based, (4) the study reported a pre- and postquantitative measure of carer depression, anxiety, stress, burden, or quality of life, (5) appeared in a peer-reviewed journal, and (6) was accessible in English.

RESULTS

A total of 46 studies were identified for inclusion through the detailed search strategy. The search was conducted, and data were extracted independently by 2 researchers. The majority of studies reported that 1 or more measures relating to carer mental health improved following receipt of a relevant intervention, with interventions for carers of people with traumatic brain injury showing a consistent link with improved outcomes.

CONCLUSIONS

Studies investigating internet-based interventions for carers of individuals with diverse psychiatric or neurological difficulties show some evidence in support of the effectiveness of these interventions. In addition, such interventions are acceptable to carers. Available evidence is of varying quality, and more high-quality trials are needed. Further research should also establish how specific intervention components, such as structure or interactivity, contribute to their overall efficacy with regard to carer mental health.

Life with FOCUS: A qualitative evaluation of the impact of a smartphone intervention on people with serious mental illness

OBJECTIVE

A growing body of literature indicates that mobile health (mHealth) interventions that utilize smartphones for illness management are feasible, acceptable, and clinically promising. In this study, we examine how individuals with serious mental illness use a mHealth intervention-FOCUS-to self-manage their illnesses. Additionally, we explored participant perceptions of the intervention's impact on their subjective illness experience.

METHOD

We analyzed qualitative data from 30 individuals with serious mental illness who participated in 1 of 2 community-based, 3-month trials of FOCUS. In Study 1, weekly calls were conducted by a mHealth specialist to facilitate and enhance intervention use. In Study 2, researchers conducted qualitative interviews to gather detailed perspectives of intervention use. Data were sampled from the weekly call notes and qualitative interviews and analyzed using a thematic and collaborative approach.

RESULTS

Thematic analyses revealed 6 recurring themes. Three themes emerged in regard to participants' ongoing daily use of FOCUS: "back-up" support, symptom management, and self-awareness. Another 3 themes emerged related to the intervention's impact on participants' recovery processes: acceptance of symptoms, motivation and supporting positive outlook.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This qualitative study offers insight into how individuals with serious mental illness made use of a mHealth intervention designed to support illness self-management. Our findings suggest that individuals may benefit differently from mHealth interventions depending on where they are in the recovery process. As mHealth interventions become increasingly popular in clinical settings, it is important to understand consumers' short-term and long-term benefits from these interventions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Psychoeducational Interventions for People with Schizophrenia: Findings from the Systematic Reviews

Aims: This systematic review examines the effectiveness of the psycho-educational interventions (PEIs) targeted at people diagnosed with schizophrenia and their primary caregivers on improving knowledge level of schizophrenia and health-related outcomes.Methods: A total of 28 studies were reviewed from December 1999 to May 2015. The methods described by Centre for Reviews and Dissemination were used to guide this review.Results: The PEIs showed consistent improvement in the knowledge level of schizophrenia among participants for various follow-up intervals. In addition, PEIs were found to be superior to treatment as usual in influencing health-related outcomes.Conclusions: Implications of the findings for mental health care practice and education and recommendations are discussed.

An Internet-Based Intervention for the Relatives of People with Mental Illnesses

Abstract. Relatives of individuals with mental illness are exposed to an elevated level of burden. Consequently, it is important to provide them with coping strategies. We explored the benefits of an online skills-training intervention. This open, uncontrolled interventional pilot study included 104 relatives of individuals with a mental illness. They participated either in a face-to-face group ( n = 60) or online intervention ( n = 44); participants were free to choose the type of intervention. Depressive symptoms and emotion regulation were assessed before and after the interventions. The analysis was based on an intention-to-treat model. About one-third of both samples did not complete the posttest assessments. The results of a multivariate analysis of variance revealed a significant effect of the interaction between time and intervention type, F(2,101) = 11.77, p < .01. Reductions in depressive symptoms, F(1,102) = 9.41, p < .01, ε2p = .08, and emotion-regulation difficulty, F(1,102) = 8.01, p < .01, ε2p = .07, following the online intervention were greater relative to the group intervention. Despite the limitations of this study because of group differences, the results demonstrated the benefits of an online intervention for the relatives. These encouraging initial results require further confirmation using a randomized controlled trial.

A web-based intervention for carers of individuals with anorexia nervosa (We Can): Trial protocol of a randomised controlled trial investigating the effectiveness of different levels of support

BACKGROUND

Anorexia nervosa (AN) is a life-threatening mental disorder that is associated with substantial caregiver burden. Carers of individuals with AN report high levels of distress and self-blame, and insufficient knowledge to help their loved ones. However, carers can have a very important role to play in aiding recovery from AN, and are often highly motivated to assist in the treatment process. This manuscript presents the protocol for a randomised controlled trial (RCT) of We Can, a web-based intervention for carers for people with AN. The study aims to investigate the effectiveness of We Can delivered with different intensities of support.

METHODS

The study takes the form of a multi-site, two-country, three group RCT, comparing We Can (a) with clinician messaging support (We Can-Ind), (b) with moderated carer chatroom support (We Can-Chat) and (c) with online forum only (We Can-Forum). Participants will be 303 carers of individuals with AN as well as, where possible, the individuals with AN themselves. Recruitment will be via specialist eating disorder services and carer support services in the UK and Germany. Randomisation of carers to one of the three intervention conditions in a 1:1:1 ratio will be stratified by whether or not the individual with AN has (a) agreed to participate in the study and (b) is a current inpatient. The We Can intervention will be provided to carers online over a period of 12 weeks. Participants will complete self-report questionnaires at pre-intervention (T1), mid-intervention (mediators only; 4-weeks post-randomisation), post-intervention (T2; 3-months post randomisation), and 6 months (T3) and 12 months (T4) after randomisation. The primary outcome variables are carer symptoms of depression and anxiety. Secondary outcome variables will be measured in both carers and individuals with AN. Secondary carer outcome variables will include alcohol and drug use and quality of life, caregiving behaviour, and the acceptability and use of We Can and associated supports. Secondary outcomes measured in individuals with AN will include eating disorder symptoms, and symptoms of depression and anxiety. The study will also evaluate the cost-effectiveness of the three We Can conditions, and test for mediators and moderators of the effects of We Can. The trial is registered at the International Standard Randomisation Controlled Trial Number (ISRCTN) database, registration number: ISRCTN11399850.

DISCUSSION

The study will provide insight into the effectiveness of We Can and its optimal method/s of delivery.

Digital Technology for Caregivers of People With Psychosis: Systematic Review

BACKGROUND

Psychotic disorders are severe mental health conditions that adversely affect the quality of life and life expectancy. Schizophrenia, the most common and severe form of psychosis affects 21 million people globally. Informal caregivers (families) are known to play an important role in facilitating patient recovery outcomes, although their own health and well-being could be adversely affected by the illness. The application of novel digital interventions in mental health care for patient groups is rapidly expanding; interestingly, however, far less is known about their role with family caregivers.

OBJECTIVE

This study aimed to systematically identify the application of digital interventions that focus on informal caregivers of people with psychosis and describe their outcomes.

METHODS

We completed a search for relevant papers in four electronic databases (EMBASE, MEDLINE, PsycINFO, and Web of Science). The search also included the Cochrane database and manual search of reference lists of relevant papers. The search was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines.

RESULTS

The search identified 9 studies derived from 8 unique datasets. Most studies were assessments of feasibility and were undertaken in the United States. Interventions were predominately Web-based, with a focus on improving the caregivers' knowledge and understanding about psychosis.

CONCLUSIONS

This study offers preliminary support for the feasibility and acceptability of digital interventions for psychosis in informal caregiver populations. However, the findings underpin a clear need for greater development in the range of caregiver-focused digital approaches on offer and robust evaluation of their outcomes. The use of digital approaches with caregiver populations seemingly lags someway behind the significant developments observed in patient groups.

Potential Benefits of Incorporating Peer-to-Peer Interactions Into Digital Interventions for Psychotic Disorders: A Systematic Review

OBJECTIVE

Peer-to-peer interactions and support groups mitigate experiences of social isolation and loneliness often reported by individuals with psychotic disorders. Online peer-to-peer communication can promote broader use of this form of social support. Peer-to-peer interactions occur naturally on social media platforms, but they can negatively affect mental health. Recent digital interventions for persons with psychotic disorders have harnessed the principles of social media to incorporate peer-to-peer communication. This review examined the feasibility, acceptability, and preliminary efficacy of recent digital interventions in order to identify strategies to maximize benefits of online peer-to-peer communication for persons with psychotic disorders.

METHODS

An electronic database search of PubMed, EMBASE, PsycINFO, Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Health Technology Assessment Database was conducted in February 2017 and yielded a total of 1,015 results. Eight publications that reported data from six independent trials and five interventions were reviewed.

RESULTS

The technology supporting peer-to-peer communication varied greatly across studies, from online forums to embedded social networking. When peer-to-peer interactions were moderated by facilitators, retention, engagement, acceptability, and efficacy were higher than for interventions with no facilitators. Individuals with psychotic disorders were actively engaged with moderated peer-to-peer communication and showed improvements in perceived social support. Studies involving service users in intervention design showed higher rates of acceptability.

CONCLUSIONS

Individuals with psychotic disorders value and benefit from digital interventions that include moderated peer-to-peer interactions. Incorporating peer-to-peer communication into digital interventions for this population may increase compliance with other evidence-based therapies by producing more acceptable and engaging online environments.

eHealth interventions for family carers of people with long term illness: A promising approach?

Family carers of people who have long term illness often experience physical and mental health morbidities, and burden. While there is good evidence to suggest that carers benefit from psychosocial interventions, these have primarily been delivered via face-to-face individual or group-formats. eHealth interventions offer a novel, accessible and self-paced approach to care delivery. Whether these are effective for carers' wellbeing has been little explored. This paper reports the first comprehensive systematic review in this area. A total of 78 studies, describing 62 discrete interventions, were identified. Interventions commonly aimed to promote carers' knowledge, self-efficacy, caregiving appraisal, and reduce global health morbidities. Interventions were offered to carers of people with a wide range of long term illness; dementia has been the most researched area, as reported in 40% of studies. Clinical and methodological heterogeneity in interventions precluded meta-analyses, and so data were analysed narratively. The most popular approach has comprised psychoeducational interventions delivered via an enriched online environment with supplementary modes of communication, such as network support with professionals and peers. Overall, carers appreciate the flexibility and self-paced nature of eHealth interventions, with high rates of satisfaction and acceptability. More studies using robust designs are needed to extend the evidence base.

[Internet-based interventions in the treatment of mental disorders : Overview, quality criteria, perspectives]

BACKGROUND

Mental disorders are frequently not or only insufficiently treated. Internet-based interventions offer the potential of closing the existing gaps in the treatment of mental disorders; however, it is very difficult for patients and providers to choose from the numerous interventions available.

OBJECTIVE

The aim of this study was to develop a set of quality criteria that can help patients and care providers to identify recommendable internet-based interventions.

METHODS

A selective literature search was carried out and the existing evidence on internet-based interventions in the treatment of mental disorders was collated. A panel of experts then developed quality criteria based on existing models for the systematic assessment of telemedicine applications.

RESULTS

Internet-based interventions are effective in the treatment of a broad range of mental disorders. The best evidence is available for depression and anxiety disorders. A set of criteria is proposed for the evaluation of available internet-based interventions using a checklist. These criteria have to be developed further with input from other stakeholders.

DISCUSSION

When taking these quality criteria into account, evidence-based interventions available on the internet can make an important contribution to improvement of the care of patients with mental disorders.

Designing eHealth Applications to Reduce Cognitive Effort for Persons With Severe Mental Illness: Page Complexity, Navigation Simplicity, and Comprehensibility

BACKGROUND

eHealth technologies offer great potential for improving the use and effectiveness of treatments for those with severe mental illness (SMI), including schizophrenia and schizoaffective disorder. This potential can be muted by poor design. There is limited research on designing eHealth technologies for those with SMI, others with cognitive impairments, and those who are not technology savvy. We previously tested a design model, the Flat Explicit Design Model (FEDM), to create eHealth interventions for individuals with SMI. Subsequently, we developed the design concept page complexity, defined via the design variables we created of distinct topic areas, distinct navigation areas, and number of columns used to organize contents and the variables of text reading level, text reading ease (a newly added variable to the FEDM), and the number of hyperlinks and number of words on a page.

OBJECTIVE

The objective of our study was to report the influence that the 19 variables of the FEDM have on the ability of individuals with SMI to use a website, ratings of a website's ease of use, and performance on a novel usability task we created termed as content disclosure (a measure of the influence of a homepage's design on the understanding user's gain of a website). Finally, we assessed the performance of 3 groups or dimensions we developed that organize the 19 variables of the FEDM, termed as page complexity, navigational simplicity, and comprehensibility.

METHODS

We measured 4 website usability outcomes: ability to find information, time to find information, ease of use, and a user's ability to accurately judge a website's contents. A total of 38 persons with SMI (chart diagnosis of schizophrenia or schizoaffective disorder) and 5 mental health websites were used to evaluate the importance of the new design concepts, as well as the other variables in the FEDM.

RESULTS

We found that 11 of the FEDM's 19 variables were significantly associated with all 4 usability outcomes. Most other variables were significantly related to 2 or 3 of these usability outcomes. With the 5 tested websites, 7 of the 19 variables of the FEDM overlapped with other variables, resulting in 12 distinct variable groups. The 3 design dimensions had acceptable coefficient alphas. Both navigational simplicity and comprehensibility were significantly related to correctly identifying whether information was available on a website. Page complexity and navigational simplicity were significantly associated with the ability and time to find information and ease-of-use ratings.

CONCLUSIONS

The 19 variables and 3 dimensions (page complexity, navigational simplicity, and comprehensibility) of the FEDM offer evidence-based design guidance intended to reduce the cognitive effort required to effectively use eHealth applications, particularly for persons with SMI, and potentially others, including those with cognitive impairments and limited skills or experience with technology. The new variables we examined (topic areas, navigational areas, columns) offer additional and very simple ways to improve simplicity.

A survey of eMedia-delivered interventions for schizophrenia used in randomized controlled trials

BACKGROUND

Randomized trials evaluating electronic Media (eMedia) delivery of interventions are increasingly frequent in mental health. Although a number of reviews have reported efficacy of these interventions, none has reviewed the type of eMedia interventions and quality of their description. We therefore decided to conduct a survey of eMedia-delivered interventions for schizophrenia.

METHODS

We surveyed all relevant trials reliably identified in the Cochrane Schizophrenia Group's comprehensive register of trials by authors working independently. Data were extracted regarding the size of the trial, interventions, outcomes and how well the intervention was described.

RESULTS

eMedia delivery of interventions is increasingly frequent in trials relevant to the care of people with schizophrenia. The trials varied considerably in sample sizes (mean =123, median =87, range =20-507), and interventions were diverse, rarely evaluating the same approaches and were poorly reported. This makes replication impossible. Outcomes in these studies are limited, have not been noted to be chosen by end users and seem unlikely to be easy to apply in routine care. No study reported on potential adverse effects or cost, end users satisfaction or ease of use. None of the papers mentioned the use of CONSORT eHealth guidelines.

CONCLUSION

There is a need to improve reporting and testing of psychosocial interventions delivered by eMedia. New trials should comply with CONSORT eHealth guidance on design, conduct and reporting, and existing CONSORT should be updated regularly, as the field is constantly evolving.

TechCare: mobile assessment and therapy for psychosis - an intervention for clients in the Early Intervention Service: A feasibility study protocol

Objectives:

Technological advances in healthcare have shown promise when delivering interventions for mental health problems such as psychosis. The aim of this project is to develop a mobile phone intervention for people with psychosis and to conduct a feasibility study of the TechCare App.

Methods:

The TechCare App will assess participant’s symptoms and respond with a personalised guided self-help-based psychological intervention with the aim of exploring feasibility and acceptability. The project will recruit 16 service users and 8–10 health professionals from the Lancashire Care NHS Foundation Trust Early Intervention Service.

Results:

In strand 1 of the study, we will invite people to discuss their experience of psychosis and give their opinions on the existing evidence-based treatment (cognitive behavioural therapy) and how the mobile app can be developed. In strand 2, we will complete a test run with a small number of participants (n = 4) to refine the mobile intervention (TechCare). Finally, in strand 3 of the study, the TechCare App will be examined in a feasibility study with 12 participants.

Conclusion:

It has been suggested that there is a need for a rapid increase in the efforts to develop the evidence base for the clinical effectiveness of digital technologies, considering mHealth research can potentially be helpful in addressing the demand on mental health services globally.

Acceptability of Interventions Delivered Online and Through Mobile Phones for People Who Experience Severe Mental Health Problems: A Systematic Review

Background

Psychological interventions are recommended for people with severe mental health problems (SMI). However, barriers exist in the provision of these services and access is limited. Therefore, researchers are beginning to develop and deliver interventions online and via mobile phones. Previous research has indicated that interventions delivered in this format are acceptable for people with SMI. However, a comprehensive systematic review is needed to investigate the acceptability of online and mobile phone-delivered interventions for SMI in depth.

Objective

This systematic review aimed to 1) identify the hypothetical acceptability (acceptability prior to or without the delivery of an intervention) and actual acceptability (acceptability where an intervention was delivered) of online and mobile phone-delivered interventions for SMI, 2) investigate the impact of factors such as demographic and clinical characteristics on acceptability, and 3) identify common participant views in qualitative studies that pinpoint factors influencing acceptability.

Methods

We conducted a systematic search of the databases PubMed, Embase, PsycINFO, CINAHL, and Web of Science in April 2015, which yielded a total of 8017 search results, with 49 studies meeting the full inclusion criteria. Studies were included if they measured acceptability through participant views, module completion rates, or intervention use. Studies delivering interventions were included if the delivery method was online or via mobile phones.

Results

The hypothetical acceptability of online and mobile phone-delivered interventions for SMI was relatively low, while actual acceptability tended to be high. Hypothetical acceptability was higher for interventions delivered via text messages than by emails. The majority of studies that assessed the impact of demographic characteristics on acceptability reported no significant relationships between the two. Additionally, actual acceptability was higher when participants were provided remote online support. Common qualitative factors relating to acceptability were safety and privacy concerns, the importance of an engaging and appealing delivery format, the inclusion of peer support, computer and mobile phone literacy, technical issues, and concerns about the impact of psychological state on intervention use.

Conclusions

This systematic review provides an in-depth focus on the acceptability of online and mobile phone-delivered interventions for SMI and identified the need for further research in this area. Based on the results from this review, we recommend that researchers measure both hypothetical and actual acceptability to identify whether initial perceptions of online and mobile phone-delivered interventions change after access. In addition, more focus is needed on the potential impact of demographic and clinical characteristics on acceptability. The review also identified issues with module completion rates and intervention use as measures of acceptability. We therefore advise researchers to obtain qualitative reports of acceptability throughout each phase of intervention development and testing. Further implications and opportunities for future research are discussed.

Effectiveness of Social Media Interventions for People With Schizophrenia: A Systematic Review and Meta-Analysis

Background

Recent studies have shown that people with serious mental disorders spend time online for the purposes of disclosure, information gathering, or gaming. However, coherent information on the effects of social media on treatment for people with schizophrenia is still lacking.

Objective

Our aim was to determine the effects of social media interventions for supporting mental health and well-being among people with schizophrenia.

Methods

A systematic review and meta-analysis were undertaken to determine the effects of social media interventions for supporting mental health and well-being among people with schizophrenia. Ten databases were searched, while search parameters included English-only manuscripts published prior to June 25, 2015. Study appraisals were made independently by 2 reviewers, and qualitative and quantitative syntheses of data were conducted.

Results

Out of 1043 identified records, only two randomized studies of moderate quality (three records, total N=331, duration 12 months) met the inclusion criteria. Participants were people with schizophrenia spectrum or an affective disorder. Social media was used as part of Web-based psychoeducation, or as online peer support (listserv and bulletin board). Outcome measures included perceived stress, social support, and disease-related distress. At 3 months, participants with schizophrenia in the intervention group reported lower perceived stress levels ( P=.04) and showed a trend for a higher perceived level of social support ( P=.06). However, those who reported more positive experiences with the peer support group also reported higher levels of psychological distress ( P=.01).

Conclusions

Despite using comprehensive searches from 10 databases, we found only two studies, whereas numerous reports have been published citing the benefits of social media in mental health. Findings suggest the effects of social media interventions are largely unknown. More research is needed to understand the effects of social media, for users with and without mental illness, in order to determine the impact on mental well-being ofsocial media use as well as its risks.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Emerging mHealth and eHealth interventions for serious mental illness: a review of the literature

BACKGROUND

Serious mental illness (SMI) is one of the leading causes of disability worldwide. Emerging mobile health (mHealth) and eHealth interventions may afford opportunities for reaching this at-risk group.

AIM

To review the evidence on using emerging mHealth and eHealth technologies among people with SMI.

METHODS

We searched MEDLINE, PsychINFO, CINAHL, Scopus, Cochrane Central, and Web of Science through July 2014. Only studies which reported outcomes for mHealth or eHealth interventions, defined as remotely delivered using mobile, online, or other devices, targeting people with schizophrenia, schizoaffective disorder, or bipolar disorder, were included.

RESULTS

Forty-six studies spanning 12 countries were included. Interventions were grouped into four categories: (1) illness self-management and relapse prevention; (2) promoting adherence to medications and/or treatment; (3) psychoeducation, supporting recovery, and promoting health and wellness; and (4) symptom monitoring. The interventions were consistently found to be highly feasible and acceptable, though clinical outcomes were variable but offered insight regarding potential effectiveness.

CONCLUSIONS

Our findings confirm the feasibility and acceptability of emerging mHealth and eHealth interventions among people with SMI; however, it is not possible to draw conclusions regarding effectiveness. Further rigorous investigation is warranted to establish effectiveness and cost benefit in this population.

Psychoeducation (brief) for people with serious mental illness

BACKGROUND

Those with serious/severe mental illness, especially schizophrenia and schizophrenic-like disorders, often have little to no insight regarding the presence of their illness. Psychoeducation may be defined as the education of a person with a psychiatric disorder regarding the symptoms, treatments, and prognosis of that illness. Brief psychoeducation is a short period of psychoeducation; although what constitutes 'brief psychoeducation' can vary. A previous systematic review has shown that the median length of psychoeducation is around 12 weeks. In this current systematic review, we defined 'brief psychoeducation' as programmes of 10 sessions or less.

OBJECTIVES

To assess the efficacy of brief psychoeducational interventions as a means of helping severely mentally ill people when added to 'standard' care, compared with the efficacy of standard care alone.The secondary objective is to investigate whether there is evidence that a particular kind (individual/ family/group) of brief psychoeducational intervention is superior to others.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group register September 2013 using the phrase:[*Psychoeducat* in interventions of STUDY]. Reference lists of included studies were also inspected for further relevant studies. We also contacted authors of included study for further information regarding further data or details of any unpublished trials.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) comparing brief psychoeducation with any other intervention for treatment of people with severe mental illness. If a trial was described as 'double blind' but implied randomisation, we entered such trials in a sensitivity analysis.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently from included papers. We contacted authors of trials for additional and missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. For continuous data, we calculated the mean difference (MD), again with 95% CIs. We used a fixed-effect model for data synthesis, and also assessed data using a random-effects model in a sensitivity analysis. We assessed risk of bias for each included study and created 'Summary of findings' tables using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

MAIN RESULTS

We included twenty studies with a total number of 2337 participants in this review. Nineteen studies compared brief psychoeducation with routine care or conventional delivery of information. One study compared brief psychoeducation with cognitive behavior therapy.Participants receiving brief psychoeducation were less likely to be non-compliant with medication than those receiving routine care in the short term (n = 448, 3 RCTs, RR 0.63 CI 0.41 to 0.96, moderate quality evidence) and medium term (n = 118, 1 RCT, RR 0.17 CI 0.05 to 0.54, low quality evidence).Compliance with follow-up was similar between the two groups in the short term (n = 30, 1 RCT, RR 1.00, CI 0.24 to 4.18), medium term (n = 322, 4 RCTs, RR 0.74 CI 0.50 to 1.09) and long term (n = 386, 2 RCTs, RR 1.19, CI 0.83 to 1.72).Relapse rates were significantly lower amongst participants receiving brief psychoeducation than those receiving routine care in the medium term (n = 406, RR 0.70 CI 0.52 to 0.93, moderate quality evidence), but not in the long term.Data from a few individual studies supported that brief psychoeducation: i) can improve the long-term global state (n = 59, 1 RCT, MD -6.70 CI -13.38 to -0.02, very low quality evidence); ii) promote improved mental state in short term (n = 60, 1 RCT, MD -2.70 CI -4.84 to -0.56,low quality evidence) and medium term; iii) can lower the incidence and severity of anxiety and depression.Social function such as rehabilitation status (n = 118, 1 RCT, MD -13.68 CI -14.85 to -12.51, low quality evidence) and social disability (n = 118, 1 RCT, MD -1.96 CI -2.09 to -1.83, low quality evidence) were also improved in the brief psychoeducation group. There was no difference found in quality of life as measured by GQOLI-74 in the short term (n = 62, 1 RCT, MD 0.63 CI -0.79 to 2.05, low quality evidence), nor the death rate in either groups (n = 154, 2 RCTs, RR 0.99, CI 0.15 to 6.65, low quality evidence).

AUTHORS' CONCLUSIONS

Based on mainly low to very low quality evidence from a limited number of studies, brief psychoeducation of any form appears to reduce relapse in the medium term, and promote medication compliance in the short term. A brief psychoeducational approach could potentially be effective, but further large, high-quality studies are needed to either confirm or refute the use of this approach.

Critical design elements of e-health applications for users with severe mental illness: singular focus, simple architecture, prominent contents, explicit navigation, and inclusive hyperlinks

OBJECTIVE

E-health applications are becoming integral components of general medical care delivery models and emerging for mental health care. Few exist for treatment of those with severe mental illness (SMI). In part, this is due to a lack of models to design such technologies for persons with cognitive impairments and lower technology experience. This study evaluated the effectiveness of an e-health design model for persons with SMI termed the Flat Explicit Design Model (FEDM).

METHODS

Persons with schizophrenia (n = 38) performed tasks to evaluate the effectiveness of 5 Web site designs: 4 were prominent public Web sites, and 1 was designed according to the FEDM. Linear mixed-effects regression models were used to examine differences in usability between the Web sites. Omnibus tests of between-site differences were conducted, followed by post hoc pairwise comparisons of means to examine specific Web site differences when omnibus tests reached statistical significance.

RESULTS

The Web site designed using the FEDM required less time to find information, had a higher success rate, and was rated easier to use and less frustrating than the other Web sites. The home page design of one of the other Web sites provided the best indication to users about a Web site's contents. The results are consistent with and were used to expand the FEDM.

CONCLUSIONS

The FEDM provides evidence-based guidelines to design e-health applications for person with SMI, including: minimize an application's layers or hierarchy, use explicit text, employ navigational memory aids, group hyperlinks in 1 area, and minimize the number of disparate subjects an application addresses.

Telepsychiatry in the assessment and treatment of schizophrenia

BACKGROUND

Telehealth technology has become more available to providers as a means of treating chronic diseases. Consideration of the applicability of telehealth technology in the treatment of schizophrenia calls for a review of the evidence base in light of the special needs and challenges in the treatment of this population. Our aims are to assess the types and nature of distant interventions for patients with schizophrenia, either telephone-based, internet-based or video-based telehealth systems.

METHODS

The following databases--MEDLINE, PsycINFO, CINAHL, the Cochrane Library, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, and EMBASE--were searched for the following terms alone or in combination with schizophrenia: telepsychiatry or telemedicine or telepsychology or satellite communication or remote communication. Inclusion criteria were: 1) articles dealing with telephone-, internet- or video-based interventions and 2) studies emphasizing development of an intervention, feasibility or clinical trials. Exclusions included were: 1) single case reports and 2) papers not written in English. With our search terms, we retrieved a total of 390 articles, of which 18 unique articles were relevant.

RESULTS

Based on the limited data available, the use of modalities involving the telephone, internet and videoconferencing appears to be feasible in patients with schizophrenia. In addition, preliminary evidence suggests these modalities appear to improve patient outcomes.

DISCUSSION

More research is needed. Investigators need to improve existing telehealth systems. In addition, researchers need to focus on developing newer interventions and determining whether these approaches can improve patient outcomes.

Technology-based interventions in social work practice: a systematic review of mental health interventions

Despite concerns around the use of technology-based interventions, they are increasingly being employed by social workers as a direct practice methodology to address the mental health needs of vulnerable clients. Researchers have highlighted the importance of using innovative technologies within social work practice, yet little has been done to summarize the evidence and collectively assess findings. In this systematic review, we describe accounts of technology-based mental health interventions delivered by social workers over the past 10 years. Results highlight the impacts of these tools and summarize advantages and disadvantages to utilizing technologies as a method for delivering or facilitating interventions.

Reducing caregiver stress with internet-based interventions: a systematic review of open-label and randomized controlled trials

OBJECTIVE

The high level of stress associated with caring for others with medical conditions has been recognized for some time. Reducing caregiver stress can improve caregiver quality of life as well as improve the care they provide to loved ones. This systematic review assesses the effectiveness of internet-based interventions to decrease caregiver stress.

MATERIALS AND METHODS

A comprehensive literature search of Ovid MEDLINE (1946-2013), Embase (1988-2013), PsycINFO (1987-2013), and CINAHL was conducted using terms related to caregiver and internet-based interventions. Internet-based interventions involving informal caregivers in an open-label or randomized controlled trial setting were included. A pair of raters independently reviewed all published abstracts. Data regarding participants, interventions, and outcomes were extracted and, for randomized trials, methodology quality was also reviewed.

RESULTS

Eight open-label trials met the review criteria: three showed positive benefit in reducing caregiver stress, four were partially positive (some outcomes positive, others negative), and one was a negative study. Sixteen randomized trials met the review criteria: six showed positive benefit, five were partially positive, and five were negative. There were no clear patterns as to the variables (such as study duration and complexity of intervention) associated with better outcomes, although earlier studies typically had more negative outcomes.

DISCUSSION

Internet-based interventions were mostly effective in reducing aspects of caregiver stress and improving their well-being. Further studies to assess outcomes for caregivers and their recipients' health, different technology delivery methods, and the cost of such interventions are needed.

Online, social media and mobile technologies for psychosis treatment: a systematic review on novel user-led interventions

BACKGROUND

Internet and mobile-based interventions provide a unique opportunity to deliver cost-effective, accessible, time-unlimited support to people with psychosis. The aims of this study were to systematically compile and analyze the evidence on the acceptability, feasibility, safety and benefits of online and mobile-based interventions for psychosis.

METHODS

Systematic review of peer-reviewed studies examining the usability, acceptability, feasibility, safety or efficacy of user-led, Internet or mobile-based interventions, with at least 80% of participants diagnosed with schizophrenia-spectrum disorders.

RESULTS

Of 38 potentially relevant articles, 12 were eligible for inclusion. Interventions included web-based psycho-education; web-based psycho-education plus moderated forums for patients and supporters; integrated web-based therapy, social networking and peer and expert moderation; web-based CBT; personalized advice based on clinical monitoring; and text messaging interventions. Results showed that 74-86% of patients used the web-based interventions efficiently, 75-92% perceived them as positive and useful, and 70-86% completed or were engaged with the interventions over the follow-up. Preliminary evidence indicated that online and mobile-based interventions show promise in improving positive psychotic symptoms, hospital admissions, socialization, social connectedness, depression and medication adherence.

CONCLUSIONS

Internet and mobile-based interventions for psychosis seem to be acceptable and feasible and have the potential to improve clinical and social outcomes. The heterogeneity, poor quality and early state of current research precludes any definite conclusions. Future research should investigate the efficacy of online and mobile interventions through controlled, well-powered studies, which investigate intervention and patient factors associated with take-up and intervention effects.

Family intervention (brief) for schizophrenia

BACKGROUND

Supportive, positive family environments have been shown to improve outcomes for patients with schizophrenia in contrast with family environments that express high levels of criticism, hostility, or over-involvement, which have poorer outcomes and have more frequent relapses. Forms of psychosocial intervention, designed to promote positive environments and reduce these levels of expressed emotions within families, are now widely used.

OBJECTIVES

To assess the effects of brief family interventions for people with schizophrenia or schizophrenia-like conditions.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (July 2012), which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. We inspected references of all identified studies for further trials. We contacted authors of trials for additional information.

SELECTION CRITERIA

All relevant randomised studies that compared brief family-oriented psychosocial interventions with standard care, focusing on families of people with schizophrenia or schizoaffective disorder were selected.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality assessed them and extracted data. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CI). For continuous outcomes, we estimated a mean difference (MD) between groups and their 95% CIs. We used GRADE to assess quality of evidence for main outcomes of interest and created a 'Summary of findings' table. We assessed risk of bias for included studies.

MAIN RESULTS

Four studies randomising 163 people could be included in the review. It is not clear if brief family intervention reduces the utilisation of health services by patients, as most results are equivocal at long term and only one study reported data for the primary outcomes of interest of hospital admission (n = 30, 1 RCT, RR 0.50, 95% CI 0.22 to 1.11, very low quality evidence). Data for relapse are also equivocal by medium term (n = 40, 1 RCT, RR 0.50, 95% CI 0.10 to 2.43, low quality evidence). However, data for the family outcome of understanding of family member significantly favoured brief family intervention (n = 70, 1 RCT, MD 14.90, 95% CI 7.20 to 22.60, very low quality evidence). No study reported data for other outcomes of interest including days in hospital; adverse events; medication compliance; quality of life or satisfaction with care; or any economic outcomes.

AUTHORS' CONCLUSIONS

The findings of this review are not outstanding due to the size and quality of studies providing data; the analysed outcomes were also minimal, with no meta-analysis possible. All outcomes in the 'Summary of findings' table were rated low or very low quality evidence. However, the importance of brief family intervention should not be dismissed outright, with the present state of demand and resources available. The designs of such brief interventions could be modified to be more effective with larger studies, which may then have enough power to inform clinical practice.