Using Contemporary Technologies in the Assessment and Treatment of Serious Mental Illness

HCI Contributions in Mental Health: A Modular Framework to Guide Psychosocial Intervention Design

Many people prefer psychosocial interventions for mental health care or other concerns, but these interventions are often complex and unavailable in settings where people seek care. Intervention designers use technology to improve user experience or reach of interventions, and HCI researchers have made many contributions toward this goal. Both HCI and mental health researchers must navigate tensions between innovating on and adhering to the theories of change that guide intervention design. In this paper, we propose a framework that describes design briefs and evaluation approaches for HCI contributions at the scopes of capabilities, components, intervention systems, and intervention implementations. We show how theories of change (from mental health) can be translated into design briefs (in HCI), and that these translations can bridge and coordinate efforts across fields. It is our hope that this framework can support researchers in motivating, planning, conducting, and communicating work that advances psychosocial intervention design.

A Mixed-Methods Implementation Evaluation of Virtual Reality Job Interview Training in IPS Supported Employment

OBJECTIVE

Employment rates among individuals with serious mental illness may be improved by engagement in the individual placement and support (IPS) model of supported employment. Results from a recent randomized controlled trial (RCT) indicate that virtual reality job interview training (VR-JIT) improves employment rates among individuals with serious mental illness who have been actively engaged in IPS for at least 90 days. This study reports on an initial implementation evaluation of VR-JIT during the RCT in a community mental health agency.

METHODS

A sequential, complementary mixed-methods design included use of qualitative data to improve understanding of quantitative findings. Thirteen IPS staff trained to lead VR-JIT implementation completed VR-JIT acceptability, appropriateness, and feasibility surveys. Participants randomly assigned to IPS with VR-JIT completed acceptability (N=42) and usability (N=28) surveys after implementation. The authors also conducted five focus groups with IPS staff (N=11) and VR-JIT recipients (N=13) and semistructured interviews with IPS staff (N=9) and VR-JIT recipients (N=4), followed by an integrated analysis process.

RESULTS

Quantitative results suggest that IPS staff found VR-JIT to be highly acceptable, appropriate for integration with IPS, and feasible for delivery. VR-JIT was highly acceptable to recipients. Qualitative results add important context to the quantitative findings, including benefits of VR-JIT for IPS staff as well as adaptations for delivering technology-based interventions to individuals with serious mental illness.

CONCLUSIONS

These qualitative and quantitative findings are consistent with each other and were influenced by VR-JIT's adaptability and perceived benefits. Tailoring VR-JIT instruction and delivery to individuals with serious mental illness may help optimize VR-JIT implementation within IPS.

Acceptability of an mHealth App for Youth With Substance Use and Mental Health Needs: Iterative, Mixed Methods Design

BACKGROUND

Treating substance use disorders (SUDs) during adolescence can prevent adult addiction and improve youth outcomes. However, it can be challenging to keep adolescents with SUDs engaged in ongoing services, thus limiting potential benefits. Developmentally appropriate tools are needed to improve treatment engagement during and between sessions for youth with SUDs and mental health disorders. Mobile health apps may augment or replace psychotherapy components; however, few have been developed specifically for youth with SUDs following user-guided design principles, which may limit their appropriateness and utility. Formative research on acceptability to intended end users is needed before the efficacy of such tools can be examined.

OBJECTIVE

This study involves user-centered, iterative development and initial user testing of a web-based app for adolescents with SUDs and mental health concerns.

METHODS

Adolescents aged 14 to 17 years with past-year involvement in outpatient psychotherapy and behavioral health clinicians with adolescent SUD treatment caseloads were recruited. Across 2 assessment phases, 40 participants (alpha: 10 youths and 10 clinicians; beta: 10 youths and 10 clinicians) viewed an app demonstration and completed semistructured interviews and questionnaires about app content and functionality.

RESULTS

Participants expressed positive impressions of the app and its potential utility in augmenting outpatient therapy for youth with SUDs and mental health concerns. Noted strengths included valuable educational content, useful embedded resources, and a variety of activities. Adolescents and clinicians favored the app over conventional (paper-and-pencil) modalities, citing convenience and familiarity. The app was found to be user-friendly and likely to improve treatment engagement. Adolescents suggested the inclusion of privacy settings, and clinicians recommended more detailed instructions and simplified language.

CONCLUSIONS

The novel app developed here appears to be a promising, acceptable, and highly scalable resource to support adolescents with SUDs and mental health concerns. Future studies should test the efficacy of such apps in enhancing adolescent behavioral health treatment engagement and outcomes.

Telehealth and Its Prospective for Improving Serious Mental Illness Conditions: A Scoping Review

BACKGROUND: Health care services ought to be continued for people with serious mental illness (SMI), despite the pandemic events. These efforts help prevent recurrences of any of these medical conditions through the use of telehealth techniques. AIM: The aim of this article is to evaluate the application of telehealth among SMI patients. METHODS: This study used a scoping review framework methodology based on the report by Arksey and O’Malley. A comprehensive literature search was carried out to identify precise studies, and vigorous criteria were employed to select the revelant papers. The search was conducted in several databases, including PubMed, CINAHL (EBSCO), and Science Direct. Subsequently, the data collected were extracted by two independent reviewers, synthesized and presented in the table and narrative format. RESULTS: A total of 13 studies were identified in the search selection process based on the review objectives, and 5 of these studies were randomized control trials (RCT), while 8 used varied research designs. CONCLUSION: Based on the results of the scoping review, telehealth services were concluded to be suitable for helping people with SMI obtain the required mental health services.

A Blended Electronic Illness Management and Recovery Program for People With Severe Mental Illness: Qualitative Process Evaluation Alongside a Randomized Controlled Trial

BACKGROUND

We conducted a trial to test the electronic Illness Management and Recovery (e-IMR) intervention to provide conclusions on the potential efficacy of eHealth for people with severe mental illness (SMI). In the e-IMR intervention, we used the standard IMR program content and methodology and combined face-to-face sessions with internet-based strategies on the constructed e-IMR internet platform. During the trial, the e-IMR platform was sparsely used.

OBJECTIVE

This study aimed to evaluate the added value of the e-IMR intervention and the barriers and facilitators that can explain the low use of the e-IMR platform.

METHODS

This process evaluation was designed alongside a multicenter, cluster randomized controlled trial. In this study, we included all available participants and trainers from the intervention arm of the trial. Baseline characteristics were used to compare users with nonusers. Qualitative data were gathered at the end of the semistructured interviews. Using theoretical thematic analyses, the data were analyzed deductively using a pre-existing coding frame.

RESULTS

Out of 41 eligible participants and 14 trainers, 27 participants and 11 trainers were interviewed. Of the 27 participants, 10 were identified as users. eHealth components that had added value were the persuasive nature of the goal-tracking sheets, monitoring, and the peer testimonials, which had the potential to enhance group discussions and disclosure by participants. The low use of the e-IMR platform was influenced by the inflexibility of the platform, the lack of information technology (IT) resources, the group context, participants' low computer skills and disabilities, and the hesitant eHealth attitude of the trainers.

CONCLUSIONS

The extent of eHealth readiness and correlations with vulnerabilities in persons with SMI need further investigation. This study shows that flexible options were needed for the use of e-IMR components and that options should be provided only in response to a participant's need. Use of the e-IMR intervention in the future is preconditioned by checking the available IT resources (such as tablets for participants) providing computer or internet guidance to participants outside the group sessions, evaluating the eHealth attitude and skills of trainers, and tailoring eHealth training to increase the skills of future e-IMR trainers.

TRIAL REGISTRATION

Netherlands Trial Register NTR4772; https://www.trialregister.nl/trial/4621.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12913-016-1267-z.

Psychiatric Risk Assessment from the Clinician's Perspective: Lessons for the Future

Accurate prediction of risk-states in Serious Mental Illnesses (SMIs) is critical for reducing their massive societal burden. Risk-state assessments are notably inaccurate. Recent innovations, including widely available and inexpensive mobile technologies for ambulatory "biobehavioral" data, can reshape risk assessment. To help understand and accelerate clinician involvement, we surveyed 90 multi-disciplinary clinicians serving SMI populations in various settings to evaluate how risk assessment is conducted and can improve. Clinicians reported considerable variability in conducting risk assessment, and few clinicians explicated their procedures beyond tying it to broader mental status examinations or interviews. Very few clinicians endorsed using currently-available standardized risk measures, and most reported low confidence in their utility. Clinicians also reported spending approximately half the time conducting individual risk assessments than optimally needed. When asked about improvement, virtually no clinicians acknowledged biobehavioral, objective technologies, or ambulatory recording. Overall, clinicians seemed unaware of meaningful ways to improve risk assessment.

Internet-based interventions to support recovery and self-management: A scoping review of their use by mental health service users and providers together

BACKGROUND

Internet-based interventions can make self-management and recovery-oriented information and tools more accessible for people experiencing severe mental illness, including psychosis. The aim of this scoping review was to identify and describe emerging joint uses of these Internet-based interventions by service users experiencing psychosis and mental health workers. It also investigated how using these Internet-based interventions influenced interactions between service users and workers and whether recovery-oriented working practices were elicited.

METHODS

A scoping review method was used. Iterative review stages included identifying the review question, a comprehensive search including searching six electronic databases to locate relevant studies, selecting studies, charting the data, and collating and reporting the results. Rigour of the scoping review was enhanced by using an appraisal tool to evaluate the quality of included studies, and by using a published template for systematic description of interventions.

RESULTS

Fifteen papers about eleven Internet-based interventions that focused on self-management and/or recovery were identified. Interventions were web-based, mobile-device based, or both. The eleven interventions were used by service users either with their usual mental health workers, or with mental health workers employed in a research project. Emerging evidence suggested that jointly using an Internet-based intervention could support a positive sense of working together. However, mismatched expectations and poor integration of Internet-based interventions into service systems could also negatively influence interactions, leading to mistrust. The interventions demonstrated potential to elicit recognised recovery-oriented practices, specifically understanding service users' values and supporting their goal striving.

CONCLUSIONS

The use of Internet-based interventions focused on self-management and recovery in mental health services by service users and workers jointly demonstrates potential to support working together and recovery-oriented practice. Given that the quality of relationships is critical in recovery-oriented practice, greater focus on human support in Internet-based interventions is needed in future research and practice.

Maximizing New Technologies to Treat Depression

In an era of rapid technological evolution, mental healthcare providers are tapping into technology that offers feasible and effective alternatives to reach patients who suffer from depression. This paper provides a brief history and description of current technologies, frequently used taxonomies, and specific applications for the assessment and treatment of depression. These include online healthcare communities and social media, automated screening, wearable technology, and virtual reality therapy. A review of a secondary analysis that incorporated technology used with patients experiencing depressive symptoms is provided and future trends in mHealth or cellular-based technologies to treat depression are explored.

E-IMR: e-health added to face-to-face delivery of Illness Management & Recovery programme for people with severe mental illness, an exploratory clustered randomized controlled trial

BACKGROUND

E-mental health holds promise for people with severe mental illness, but has a limited evidence base. This study explored the effect of e-health added to face-to-face delivery of the Illness Management and Recovery Programme (e-IMR).

METHOD

In this multi-centre exploratory cluster randomized controlled trial, seven clusters (n = 60; 41 in intervention group and 19 in control group) were randomly assigned to e-IMR + IMR or IMR only. Outcomes of illness management, self-management, recovery, symptoms, quality of life, and general health were measured at baseline (T₀), halfway (T₁), and at twelve months (T₂). The data were analysed using mixed model for repeated measurements in four models: in 1) we included fixed main effects for time trend and group, in 2) we controlled for confounding effects, in 3) we controlled for interaction effects, and in 4) we performed sub-group analyses within the intervention group.

RESULTS

Notwithstanding low activity on e-IMR, significant effects were present in model 1 analyses for self-management (p = .01) and recovery (p = .02) at T₁, and for general health perception (p = .02) at T₂, all in favour of the intervention group. In model 2, the confounding covariate gender explained the effects at T₁ and T₂, except for self-management. In model 3, the interacting covariate non-completer explained the effects for self-management (p = .03) at T₁. In model 4, the sub-group analyses of e-IMR-users versus non-users showed no differences in effect.

CONCLUSION

Because of confounding and interaction modifications, effectiveness of e-IMR cannot be concluded. Low use of e-health precludes definite conclusions on its potential efficacy. Low use of e-IMR calls for a thorough process evaluation of the intervention.

TRIAL REGISTRATION

The Dutch Trial Register ( NTR4772 ).

Smartphone-based ecological momentary assessment and intervention in a blended coping-focused therapy for distressing voices: Development and case illustration

Common approaches to the psychological treatment of distressing voice hearing experiences, such as cognitive behavioural therapy, aim to promote more adaptive cognitive, emotional and behavioural responses to these experiences. Digital technologies such as smartphones show promise for supporting and enhancing these treatments by linking immediate therapeutic settings to the context of daily life. Two promising technologies include ecological momentary assessment and intervention (EMA/I), which may offer a means of advanced assessment and support in daily life, and inform the tailoring of interventions to suit individual needs. In this study, a highly novel intervention approach was developed involving four face-to-face sessions with a psychologist blended with EMA/I between sessions in order to improve coping with distressing voice hearing experiences. The authors describe the background and development of this approach along-side a single case illustration, which supported feasibility and acceptability. This study details how digital technologies such as EMA/I may be used in future as clinical tools to enhance standard psychological treatments and clinical care of people with persisting and distressing experiences.

The WorkingWell Mobile Phone App for Individuals With Serious Mental Illnesses: Proof-of-Concept, Mixed-Methods Feasibility Study

BACKGROUND

The disparities in employment for individuals with serious mental illnesses have been well documented, as have the benefits of work. Mobile technology can provide accessible in-the-moment support for these individuals. The WorkingWell mobile app was developed to meet the need for accessible follow-along supports for individuals with serious mental illnesses in the workplace.

OBJECTIVE

We explore the usability, usage, usefulness, and overall feasibility of the WorkingWell mobile app with individuals with serious mental illnesses who are actively employed and receiving community-based services.

METHODS

In this proof-of-concept, mixed-methods, 2-month feasibility study (N=40), employed individuals with serious mental illnesses were recruited in mental health agencies. Participants completed surveys regarding background characteristics and cellphone use at enrollment and responded to interview items regarding app usability, usage, and usefulness in technical assistance calls at 1, 2, 4, and 6 weeks of participation and in the exit interview at 8 weeks. Data on the frequency of app usage were downloaded on a daily basis. A version of the System Usability Scale (SUS) was administered in the exit interview. Overall feasibility was determined by the percent of users completing the study, responses to an interview item regarding continued use, and findings on usability, usage, and usefulness. General impressions were obtained from users regarding user support materials, technical assistance, and study procedures.

RESULTS

Most participants were male (60%, 24/40), aged 55 or younger (70%, 28/40), white (80%, 32/40), had less than a 4-year college education (78%, 31/40), were employed part-time (98%, 39/40), had been working more than 6 months (60%, 24/40), and indicated a diagnosis of bipolar, schizoaffective, or depressive disorder (84%, 16/25). The majority of participants owned cellphones (95%, 38/40) and used them multiple times per day (83%, 33/40). Their average rating on SUS usability items was 3.93 (SD 0.77, range 1.57-5.00), reflecting positive responses. In general, participants indicated WorkingWell was "very easy," "straightforward," "simple," and "user friendly." Usability challenges were related to personal issues (eg, memory) or to difficulties with the phone or app. Data on app usage varied considerably. The most frequent navigations were to the home screen, followed by Rate My Day and My Progress, and then by Manage the Moment and Remind Me. The app was described as useful by most participants; 86% (30/35) agreed the app would help them manage better on the job. Of the 40 original participants, 35 (87%) completed the study.

CONCLUSIONS

The WorkingWell app is a feasible approach to providing accessible, as-needed employment support for individuals with serious mental illnesses. The app would benefit from modifications to address recommendations from feasibility testing. Controlled research with larger samples, more diverse in individual characteristics and workplace settings, is essential to demonstrating the effectiveness of the app.

Recovery After Psychosis: Qualitative Study of Service User Experiences of Lived Experience Videos on a Recovery-Oriented Website

BACKGROUND

Digital interventions offer an innovative way to make the experiences of people living with mental illness available to others. As part of the Self-Management And Recovery Technology (SMART) research program on the use of digital resources in mental health services, an interactive website was developed including videos of people with lived experience of mental illness discussing their recovery. These peer videos were designed to be watched on a tablet device with a mental health worker, or independently.

OBJECTIVE

Our aim was to explore how service users experienced viewing the lived experience videos on this interactive website, as well as its influence on their recovery journey.

METHODS

In total, 36 service users with experience of using the website participated in individual semistructured qualitative interviews. All participants had experience of psychosis. Data analysis occurred alongside data collection, following principles of constructivist grounded theory methodology.

RESULTS

According to participants, engaging with lived experience videos was a pivotal experience of using the website. Participants engaged with peers through choosing and watching the videos and reflecting on their own experience in discussions that opened up with a mental health worker. Benefits of seeing others talking about their experience included "being inspired," "knowing I'm not alone," and "believing recovery is possible." Experiences of watching the videos were influenced by the participants' intrapersonal context, particularly their ways of coping with life and use of technology. The interpersonal context of watching the videos with a worker, who guided website use and facilitated reflection, enriched the experience.

CONCLUSIONS

Engaging with lived experience videos was powerful for participants, contributing to their feeling connected and hopeful. Making websites with lived experience video content available to service users and mental health workers demonstrates strong potential to support service users' recovery.

Going Online Together: The Potential for Mental Health Workers to Integrate Recovery Oriented E-Mental Health Resources Into Their Practice

BACKGROUND

The Internet offers a growing range of e-mental health resources for people experiencing severe mental illness. How these resources may be used in face-to-face interactions with consumers in mental health practice is not well understood.

AIM

This article explores mental health workers' current use of online resources and their views about integrating e-mental health resources for promoting self-management and recovery into community-based practice.

METHOD

A total of 37 mental health workers from six services attended focus groups to discuss their views about using online and e-mental health resources in face-to-face interactions with consumers. Data were analyzed using qualitative content analysis.

RESULTS

Participants described accessing Internet information but having little opportunity to use online resources with consumers. Limited access to mobile technology and perceptions that consumers lacked technological experience constrained current use. Three approaches to using e-mental health resources were perceived: directing, collaborating, and empowering. Access to mobile technology within worker-consumer interactions was identified as a potential catalyst for creating recovery-oriented therapeutic relationships.

CONCLUSION

Mental health workers are ready to grasp opportunities to use e-mental health resources with consumers. This has the potential to develop and strengthen collaborative, partnership-based relationships if mental health services support workers and consumers to use online resources together.

Technology to assess and support self-management in serious mental illness

The functional impairment associated with serious mental illness (SMI) places an immense burden on individuals and society, and disability often persists even after efficacious treatment of psychopathologic symptoms. Traditional methods of measuring functioning have limitations, and numerous obstacles reduce the reach and impact of evidence-based interventions developed to improve functioning in SMI. This review describes the potential of technological innovations for overcoming the challenges involved in both functional assessment and intervention in people with SMI. Ecological momentary assessment (EMA), which involves the repeated sampling of naturalistic behaviors and experiences while individuals carry out their daily lives, has provided a new window through which the determinants of day-to-day function in SMI can be observed. EMA has several advantages over traditional assessment methods and has in recent years evolved to use mobile-based platforms, such as text messaging and smartphone applications, for both assessment and promotion of self-management in people with SMI. We will review promising data regarding the acceptability, adherence, and efficacy of EMA-based mobile technologies; explore ways in which these technologies can extend the reach and impact of evidence-based psychosocial rehabilitative interventions in SMI; and outline future directions for research in this important area.

Switched on or switched off? A survey of mobile, computer and Internet use in a community mental health rehabilitation sample

BACKGROUND

UK society is undergoing a technological revolution, including meeting health needs through technology. Government policy is shifting towards a "digital by default" position. Studies have trialled health technology interventions for those experiencing psychosis and shown them to be useful.

AIMS

To gauge levels of engagement with mobile phones (Internet-enabled or cell phone), computers and the Internet in the specific population of community mental health rehabilitation.

METHOD

Two surveys were conducted: with service-users on use/non-use of technologies, and interest in technology interventions and support; and with placements on facilities and support available to service-users.

RESULTS

Levels of engagement in this population were substantially less than those recorded in the general UK and other clinical populations: 40.2% regularly use mobiles, 17.5% computers, and 14.4% the Internet. Users of all three technologies were significantly younger than non-users. Users of mobiles and computers were significantly more likely to live in lower support/higher independence placements. Of surveyed placements, 35.5% provide a communal computer and 38.7% IT skills sessions.

CONCLUSIONS

Community mental health rehabilitation service-users risk finding themselves excluded by a "digital divide". Action is needed to ensure equal access to online opportunities, including healthcare innovations. Clinical and policy implications are discussed.

Strategies for mHealth research: lessons from 3 mobile intervention studies

The capacity of Mobile Health (mHealth) technologies to propel healthcare forward is directly linked to the quality of mobile interventions developed through careful mHealth research. mHealth research entails several unique characteristics, including collaboration with technologists at all phases of a project, reliance on regional telecommunication infrastructure and commercial mobile service providers, and deployment and evaluation of interventions "in the wild", with participants using mobile tools in uncontrolled environments. In the current paper, we summarize the lessons our multi-institutional/multi-disciplinary team has learned conducting a range of mHealth projects using mobile phones with diverse clinical populations. First, we describe three ongoing projects that we draw from to illustrate throughout the paper. We then provide an example for multidisciplinary teamwork and conceptual mHealth intervention development that we found to be particularly useful. Finally, we discuss mHealth research challenges (i.e. evolving technology, mobile phone selection, user characteristics, the deployment environment, and mHealth system "bugs and glitches"), and provide recommendations for identifying and resolving barriers, or preventing their occurrence altogether.

Randomised controlled trial of a digitally assisted low intensity intervention to promote personal recovery in persisting psychosis: SMART-Therapy study protocol

BACKGROUND

Psychosocial interventions have an important role in promoting recovery in people with persisting psychotic disorders such as schizophrenia. Readily available, digital technology provides a means of developing therapeutic resources for use together by practitioners and mental health service users. As part of the Self-Management and Recovery Technology (SMART) research program, we have developed an online resource providing materials on illness self-management and personal recovery based on the Connectedness-Hope-Identity-Meaning-Empowerment (CHIME) framework. Content is communicated using videos featuring persons with lived experience of psychosis discussing how they have navigated issues in their own recovery. This was developed to be suitable for use on a tablet computer during sessions with a mental health worker to promote discussion about recovery.

METHODS/DESIGN

This is a rater-blinded randomised controlled trial comparing a low intensity recovery intervention of eight one-to-one face-to-face sessions with a mental health worker using the SMART website alongside routine care, versus an eight-session comparison condition, befriending. The recruitment target is 148 participants with a schizophrenia-related disorder or mood disorder with a history of psychosis, recruited from mental health services in Victoria, Australia. Following baseline assessment, participants are randomised to intervention, and complete follow up assessments at 3, 6 and 9 months post-baseline. The primary outcome is personal recovery measured using the Process of Recovery Questionnaire (QPR). Secondary outcomes include positive and negative symptoms assessed with the Positive and Negative Syndrome Scale, subjective experiences of psychosis, emotional symptoms, quality of life and resource use. Mechanisms of change via effects on self-stigma and self-efficacy will be examined.

DISCUSSION

This protocol describes a novel intervention which tests new therapeutic methods including in-session tablet computer use and video-based peer modelling. It also informs a possible low intensity intervention model potentially viable for delivery across the mental health workforce.

TRIAL REGISTRATION

NCT02474524 , 24 May 2015, retrospectively registered during the recruitment phase.

Perspectives on the Use of eHealth in the Management of Patients With Schizophrenia

Mobile devices, digital technologies, and web-based applications-known collectively as eHealth (electronic health)-could improve health care delivery for costly, chronic diseases such as schizophrenia. Pharmacologic and psychosocial therapies represent the primary treatment for individuals with schizophrenia; however, extensive resources are required to support adherence, facilitate continuity of care, and prevent relapse and its sequelae. This paper addresses the use of eHealth in the management of schizophrenia based on a roundtable discussion with a panel of experts, which included psychiatrists, a medical technology innovator, a mental health advocate, a family caregiver, a health policy maker, and a third-party payor. The expert panel discussed the uses, benefits, and limitations of emerging eHealth with the capability to integrate care and extend service accessibility, monitor patient status in real time, enhance medication adherence, and empower patients to take a more active role in managing their disease. In summary, to support this technological future, eHealth requires significant research regarding implementation, patient barriers, policy, and funding.

Caregiver burden as a predictor of depression among family and friends who provide care for persons with bipolar disorder

OBJECTIVES

Over one-third of caregivers of people with bipolar disorder report clinically significant levels of depressive symptoms. This study examined the causal relationship between depression and caregiver burden in a large sample of caregivers of adult patients with bipolar disorder.

METHODS

Participants were 500 primary caregivers of persons with bipolar disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).This study evaluates the strength and direction of the associations between caregiver burden and depressive symptoms at baseline and at six- and 12-month follow-up using cross-lagged panel analyses, controlling for the clinical status of patients and sociodemographic variables.

RESULTS

Higher levels of overall caregiver burden at baseline were associated with increased levels of depressive symptoms among caregivers at follow-up (F = 8.70, df = 1,290, p < 0.001), after controlling for baseline caregiver depression, gender, race, age, social support, and patients' clinical status. By contrast, caregiver depression at baseline was not significantly associated with caregiver burden at follow-up (F = 1.65, p = 0.20).

CONCLUSIONS

Caregiver burden is a stronger predictor of caregiver depressive symptoms over time than the reverse. Interventions that help alleviate caregiver burden may decrease depressive symptoms.

Development of an e-supported illness management and recovery programme for consumers with severe mental illness using intervention mapping, and design of an early cluster randomized controlled trial

Background

E-mental health is a promising medium to keep mental health affordable and accessible. For consumers with severe mental illness the evidence of the effectiveness of e-health is limited. A number of difficulties and barriers have to be addressed concerning e-health for consumers with severe mental illness. One possible solution might be to blend e-health with face-to-face delivery of a recovery-oriented treatment, like the Illness Management & Recovery (IMR) programme. This paper describes the development of an e-health application for the IMR programme and the design of an early clustered randomized controlled trial.

Method/Design

We developed the e-IMR intervention according to the six-step protocol of Intervention Mapping. Consumers joined the development group to address important and relevant issues for the target group. Decisions during the six-step development process were based on qualitative evaluations of the Illness Management & Recovery programme, structured interviews, discussion in the development group, and literature reviews on qualitative papers concerning consumers with severe mental illness, theoretical models, behavioural change techniques, and telemedicine for consumers with severe mental illness. The aim of the e-IMR intervention is to help consumers with severe mental illness to involve others, manage achieving goals, and prevent relapse. The e-IMR intervention consists of face-to-face delivery of the Illness Management & Recovery programme and an e-health application containing peer-testimonials on videos, follow up on goals and coping strategies, monitoring symptoms, solving problems, and communication opportunities.

We designed an early cluster randomized controlled trial that will evaluate the e-IMR intervention. In the control condition the Illness Management & Recovery programme is provided. The main effect-study parameters are: illness management, recovery, psychiatric symptoms severity, self-management, quality of life, and general health. The process of the IMR program will be evaluated on fidelity and feasibility in semi-structured interviews with participants and trainers.

Discussion

Intervention Mapping provided a systematic procedure for the development of this e-health intervention for consumers with severe mental illness and the preparation of an early randomized controlled trial.

Trial Registration

The trial is registered in the Dutch Trial Register: NTR4772 .

Technology-based interventions for psychiatric illnesses: improving care, one patient at a time

Worldwide, individuals with severe psychiatric illnesses struggle to receive evidence-based care. While science has made remarkably slow progress in the development and implementation of effective psychiatric treatments, we have witnessed enormous progress in the emergence and global penetration of personal computing technology. The present paper examines how digital resources that are already widespread (e.g., smartphones, laptop computers), can be leveraged to support psychiatric care. These instruments and implementation strategies can increase patient access to evidenced-based care, help individuals overcome the barriers associated with the stigma of mental illness, and facilitate new treatment paradigms that harness wireless communication, sensors and the Internet, to enhance treatment potency. Innovative digital treatment programmes that have been used successfully with a range of conditions (i.e., schizophrenia, posttraumatic stress disorder and borderline personality disorder) are presented in the paper to demonstrate the utility and potential impact of technology-based interventions in the years ahead.

Feasibility, acceptability, and preliminary efficacy of a smartphone intervention for schizophrenia

The FOCUS smartphone intervention was developed to provide automated real-time/real-place illness management support to individuals with schizophrenia. The system was specifically designed to be usable by people with psychotic disorders who may have cognitive impairment, psychotic symptoms, negative symptoms, and/or low reading levels. FOCUS offers users both prescheduled and on-demand resources to facilitate symptom management, mood regulation, medication adherence, social functioning, and improved sleep. In this study, 33 individuals with schizophrenia or schizoaffective disorder used FOCUS over a 1-month period in their own environments. Participants were able to learn how to use the intervention independently, and all but one participant completed the trial successfully and returned the smartphones intact. Completers used the system on 86.5% of days they had the device, an average of 5.2 times a day. Approximately 62% of use of the FOCUS intervention was initiated by the participants, and 38% of use was in response to automated prompts. Baseline levels of cognitive functioning, negative symptoms, persecutory ideation, and reading level were not related to participants' use of the intervention. Approximately 90% of participants rated the intervention as highly acceptable and usable. Paired samples t tests found significant reductions in psychotic symptoms, depression, and general psychopathology, after 1 month of FOCUS use. This study demonstrated the feasibility, acceptability, and preliminary efficacy of the FOCUS intervention for schizophrenia and introduces a new treatment model which has promise for extending the reach of evidence-based care beyond the confines of a physical clinic using widely available technologies.

Mobile health (mHealth) for mental health in Asia: objectives, strategies, and limitations

Mobile technologies are transforming the way in which we interact with one another, access resources, find information, and conduct business around the world. Harnessing the capabilities of mobile technologies to support health care initiatives worldwide has developed into a new interdisciplinary field called mobile health (mHealth). In the current paper, we review the penetration of mobile technology in Asia, and consider the integration of mobile technologies into the study, diagnoses, and treatment of mental disorders in the region. We outline how mHealth programs could improve mental health literacy, provide greater access to mental health services, extend community-based outreach and engagement, support self-management of illness, and regulate medication distribution. We end with a consideration of the potential barriers and limitations of mHealth for mental health, including funding, language and literacy barriers, power supply considerations, data security, and privacy issues.

Recovery and severe mental illness: description and analysis

The notion of recovery has been embraced by key stakeholders across Canada and elsewhere. This has led to a proliferation of definitions, models, and research on recovery, making it vitally important to examine the data to disentangle the evidence from the rhetoric. In this paper, first we ask, what do people living with severe mental illness (SMI) say about recovery in autobiographical accounts? Second, what do they say about recovery in qualitative studies? Third, from what we have uncovered about recovery, can we learn anything from quantitative studies about proportions of people leading lives of recovery? Finally, can we identify interventions and approaches that may be consistent or inconsistent with the grounded notions of recovery unearthed in this paper? We found that people with mental illness frequently state that recovery is a journey, characterized by a growing sense of agency and autonomy, as well as greater participation in normative activities, such as employment, education, and community life. However, the evidence suggests that most people with SMI still live in a manner inconsistent with recovery; for example, their unemployment rate is over 80%, and they are disproportionately vulnerable to homelessness, stigma, and victimization. Research stemming from rehabilitation science suggests that recovery can be enhanced by various evidence-based services, such as supported employment, as well as by clinical approaches, such as shared decision making and peer support. But these are not routinely available. As such, significant systemic changes are necessary to truly create a recovery-oriented mental health system.

Web-based behavioral treatment for substance use disorders as a partial replacement of standard methadone maintenance treatment

This study is the first experimental trial to evaluate the effectiveness of a Web-based behavioral intervention when deployed in a model where it partially substituted for standard counseling in a community-based specialty addiction treatment program. New opioid-dependent intakes in methadone maintenance treatment (n=160) were randomly assigned for 12months to either: (1) standard treatment or (2) reduced standard treatment plus a Web-based psychosocial intervention, the Therapeutic Education System (TES). Results demonstrated that replacing a portion of standard treatment with TES resulted in significantly greater rates of objectively measured opioid abstinence (48% vs. 37% abstinence across all study weeks; F(1, 158)=5.90, p<.05 and 59% vs. 43% abstinence on weeks participants provided urine samples for testing; F(1, 158)=8.81, p<.01). This result was robust and was evident despite how opioid abstinence was operationally defined and evaluated. The potential implications for service delivery models within substance abuse treatment programs and other healthcare entities are discussed.