Clinical outcomes from the texting for relapse prevention (T4RP) in schizophrenia and schizoaffective disorder study

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Digital health interventions to improve adherence to oral antipsychotics among patients with schizophrenia: a scoping review

OBJECTIVES

To assess the current evidence on the potential of digital health interventions (DHIs) to improve adherence to oral antipsychotics among patients with schizophrenia by assessing the methodologies, feasibility and effectiveness of DHIs as well as the perceptions of relevant stakeholders.

DESIGN

The scoping review was conducted based on the methodologies outlined by Levac et al and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

DATA SOURCES

PubMed, Embase, Web of Science, Scopus, CINAHL, PsycINFO and the Cochrane Library were searched in August 2023 to identify relevant publications from the previous decade.

ELIGIBILITY CRITERIA

Studies published in English focused on improving medication adherence among adult patients with schizophrenia or schizoaffective disorder via DHIs were selected. Protocols, editorials, comments, perspectives, reviews, correspondence and conference abstracts were excluded.

DATA EXTRACTION AND SYNTHESIS

The extracted data included general information about the study, framework, participants, features and strategies of DHIs, measurement tools for adherence used, and main findings.

RESULTS

In total, 64 studies were included in the qualitative synthesis. Features used in DHIs to improve medication adherence included phone calls, text messages, mobile apps, sensors, web-based platforms and electronic devices. Strategies included medication reminders and monitoring, providing medication-related information and suggestions, other illness management suggestions and individual support. Texting and mobile apps were commonly used as medication reminders and monitoring methods. Additionally, the use of sensors combined with other digital technologies has garnered significant attention. All the interventions were considered acceptable and feasible, and several were assessed in pilot trials. Preliminary findings suggest that DHIs could enhance medication adherence in patients with schizophrenia. However, further validation of their effectiveness is required.

CONCLUSION

DHIs are a promising approach to enhancing medication adherence among patients with schizophrenia. Future interventions should be interactive, focusing on user preference, experience and privacy.

[Effect of Digital Health Interventions on Psychotic Symptoms among Persons with Severe Mental Illness in Community: A Systematic Review and Meta-Analysis]

PURPOSE

This study aimed to evaluate the effects of digital health interventions on the psychotic symptoms among people with severe mental illness in the community.

METHODS

A systematic review and meta-analysis were conducted in accordance with the Cochrane Intervention Research Systematic Review Manual and PRISMA. A literature search was conducted of published randomized controlled trials (RCTs) for digital health interventions from January 2022 to April 2022. RevMan software 5.3 was used for quality assessment and meta-analysis.

RESULTS

A total 14 studies out of 9,864 studies were included in the review, and 13 were included in meta-analysis. The overall effect size of digital health interventions on psychotic symptoms was -0.21 (95% CI = -0.32 to -0.10). Sub-analysis showed that the reduction of the psychotic symptoms was effective in the schizophrenia spectrum group (SMD = -.0.22; 95% CI = -.0.36 to -0.09), web (SMD = -0.41; 95% CI = -0.82 to 0.01), virtual reality (SMD = -0.33; 95% CI = -0.56 to -0.10), mobile (SMD = -0.15; 95% CI = -0.28 to -0.03), intervention period of less than 3 months (SMD = -0.23; 95% CI = -0.35 to -0.11), and non-treatment group (SMD = -0.23; 95% CI = -0.36 to -0.11).

CONCLUSION

These findings suggest that digital health interventions alleviate psychotic symptoms in patients with severe mental illnesses. However, well-designed digital health studies should be conducted in the future.

Systematic Literature Review of Text Messaging Interventions to Promote Medication Adherence Among People With Serious Mental Illness

OBJECTIVE

Mobile health tools are feasible options to encourage behavior change among patients with serious mental illness. Mobile health tools vary widely, both in platforms used and content delivered. This literature review assessed the use of text messaging interventions to promote medication adherence among patients with serious mental illness.

METHODS

A systematic literature review using PRISMA guidelines examined short message service (SMS) text messaging interventions promoting medication adherence to people with a serious mental illness diagnosis. Databases included PubMed, Cochrane, CINAHL, and PsycINFO. Data extraction included demographic information, participant diagnoses, intervention components, medication class, adherence measures, research design, and study outcomes. Study quality was also assessed.

RESULTS

Of 114 full-text articles screened, 10 articles were selected from nine unique interventions (N=937 people with serious mental illness). Study durations ranged from 30 days to 18 months, with frequency of SMS ranging from twice weekly to 12 times daily. Of the nine unique trials, most reported using an automated server to deliver SMS messages (N=7), two-way SMS capabilities (N=6), customized message content or timing (N=7), and additional components (e.g., provider contact, educational content, and monetary rewards) (N=7). Seven of the 10 articles reported statistically significant improvement in medication adherence and in at least one clinical outcome.

CONCLUSIONS

Evidence to date indicates that text messaging interventions are feasible and appear to improve medication adherence and clinical outcomes among patients with serious mental illness. Future research should assess implementation approaches and how to scale up efforts in nonresearch settings.

Acceptability of Texting 4 Relapse Prevention, Text Messaging-Based Relapse Prevention Program for People With Schizophrenia and Schizoaffective Disorder

ABSTRACT

We report process outcomes of the pilot randomized controlled trial of Texting 4 Relapse Prevention (T4RP), a text messaging-based relapse prevention program for people with schizophrenia or schizoaffective disorder (SAD). Forty people were randomized to either the intervention or treatment as usual control group at a 2:1 ratio. Process indicators were collected at 6 months post enrollment.Over 90% of patients agreed or strongly agreed that the text messages were easy to understand, easy to answer, positive, and helped them feel supported. Patient acceptability was positively associated with recovery (β = 0.29, p = <0.001) and patient-provider communication scores (β = 1.04, p < 0.001), and negatively associated with symptoms of the disorder (β = -0.27, p = 0.07). Acceptability was similar by diagnosis (β, SAD diagnosis = 0.40, p = 0.90) and age (β = 0.05, p = 0.67). Findings suggest that a text messaging intervention aimed at preventing relapse is feasible and perceived as beneficial in individuals with schizophrenia and SAD. Future research might include a targeted study of T4RP within the context of hospital discharge when people with schizophrenia/SAD are at highest risk of relapse.