Feedback on SMS reminders to encourage adherence among patients taking antipsychotic medication: a cross-sectional survey nested within a randomised trial

Hybrid mHealth care: Patient perspectives of blended treatments for psychosis. A systematic review

BACKGROUND

mHealth interventions use mobile and wireless technologies to deliver aspects of healthcare, and have been extensively employed in mental health research, showcasing their potential to address the significant treatment gap. While numerous studies underscore the advantages and functionalities of mHealth, challenges persist regarding patient uptake and sustained engagement among individuals with psychosis spectrum disorder. This review aims to explore individual-level barriers and facilitators to engagement with hybrid digital systems, which involves the integration of digital tools alongside in-person care.

METHOD

Four electronic databases (Medline, Web of Science, CINAHL, and PsychINFO) were systematically searched to identify hybrid digital interventions for psychosis spectrum disorders. Studies that only reported the efficacy of the interventions were excluded. 16 studies were included in the final review.

RESULTS

Six themes were identified in this review, including mHealth as a tool to aid communication, the central role of the therapist, an increased sense of support through the provision of digital support, allowing greater insight into auditory hallucinations, enabling technologies and barriers to engagement.

CONCLUSIONS

This review demonstrated the factors impacting engagement in hybrid interventions for psychosis spectrum disorder. By identifying barriers and facilitators, the findings could offer valuable guidance for the design of innovative digital interventions. These findings also underscore the importance of prioritising trustworthiness in digital systems. Future research should focus on establishing and implementing trustworthy digital systems to enhance engagement and effectively integrate mobile health into conventional healthcare practices.

A qualitative exploration of perceived needs and barriers of individuals with schizophrenia, caregivers and clinicians in using mental health applications in Madhya Pradesh, India

Introduction

About 3.5 million people are living with schizophrenia in India, with most failing to receive minimally adequate care. Digital mental health applications could potentially decrease this treatment gap; however, these applications should be tailored to meet the needs and overcoming barriers of its end-users to ensure their adoption and sustained usage. Few studies in India have explored the perspectives of target stakeholders to understand how digital tools could be viable for supporting care. Therefore, this study explores the perceived needs and barriers of patients with schizophrenia, caregivers and clinicians in using digital mental health applications.

Methods

Focus group discussions (FGDs) were conducted with patients having schizophrenia attending outpatient clinics at a government tertiary hospital, and their caregivers, and mental health clinicians in Bhopal, Madhya Pradesh, India. FGDs were audio-recorded and coded. Framework analysis was employed to guide the analysis, involving deductive and inductive generation of themes, data triangulation and comparison of perspectives between participant groups.

Results

Six FGDs were conducted with individuals with schizophrenia (n ​= ​11), their caregivers (n ​= ​14), and mental health clinicians (n ​= ​19). Four a priori themes were established: a) Prior experiences with health applications; b) Content of a mental health application; c) Involvement of caregivers in mental health application usage and d) Supporting doctors' work through mental health applications. Additionally, two themes were generated inductively: a) Qualities of a mental health application and b) Data privacy and confidentiality.

Conclusion

Exploration of stakeholder perspectives on the content, features, and uses of mental health applications is crucial to yield initial insights about the use of these digital programs in India. This study generated a multitude of suggestions on app functionality and components, which can guide ongoing efforts to develop and deliver digital mental health applications for patients living with schizophrenia in low-resource settings, with limited access to mental health services.

The Safety and Efficacy of Psychosocial Adherence Interventions in Young People with Early Psychosis: A Systematic Review

Background: The role of antipsychotic medication in supporting young people in their recovery from early psychosis is complex and controversial. It is common for young people, often given antipsychotic medication for the first time, to express a choice to stop treatment, potentially increasing the risk of relapse and admission to hospital. Our systematic review aimed to evaluate the safety and effectiveness of psychosocial interventions to enhance antipsychotic medication adherence in young people with early psychosis. Methods: We reviewed studies using any experimental design of psychosocial interventions specifically focused on enhancing adherence with antipsychotic medication in young people with early psychosis. Cochrane CENTRAL Register, Medline, Embase, PsychINFO and CINAHL were searched on 19 November 2021 without time restriction. Studies were assessed for quality using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results: Our initial search identified 3469 documents. Following title, abstract and full-text screening, we included three published studies and one unpublished experimental study that met our inclusion criteria. Outcome data were available for three studies that tested adherence–coping–education, adherence therapy, and a health dialogue intervention, all having a positive effect on medication adherence. None of the trials reported data on the safety of the experimental interventions. Conclusion: There is a paucity of evidence from high-quality randomized controlled trials that establish the safety and effectiveness of any type of psychosocial intervention to enhance medication adherence in young people with early psychosis. Further high-quality trials are warranted. This review was registered on the Open Science Framework prior to undertaking out initial searches.

Human Connection and Technology Connectivity: A Systematic Review of Available Telehealth Survey Instruments

CONTEXT

The current upsurge in telehealth use in palliative and hospice care warrants consideration of patient, family caregiver, and interdisciplinary palliative perspectives on telehealth modality and communication experiences. Currently, telehealth experiences and encounters are being described but not yet extensively evaluated by palliative care teams.

OBJECTIVES

To locate survey instruments available to assess telehealth interactions, to determine the content and constructs covered by the available instruments, and to describe the patient populations previously surveyed by the existing instruments.

METHODS

This study and its reporting followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with the protocol registered in The International Prospective Register of Systematic Reviews. Three databases were searched with over 3100 articles analyzed for use of a telehealth survey instrument.

RESULTS

Twelve telehealth communication assessment instruments were identified with a mean length of 20 questions, primarily Likert-scale responses with one inclusive of free text and one qualitative inquiry survey. Three inquired only into modality, four queried communication, and five studied both modality and communication experience. Existing telehealth survey instruments are unidirectional in exploring patient or family experience, with two inclusive of provider perspectives. Participant demographics are notably underreported in telehealth experience studies with a frank lack of diversity in ethnic/racial, geographic, age, educational, and income representativeness in current telehealth survey instrument respondents.

CONCLUSION

Palliative care teams may consider familiarity with telehealth survey instrument as an essential component to progress from description of telehealth use to evaluation of telehealth encounters. Current survey instrument outcome reports do not represent inclusivity or diversity, although telehealth is now being clinically applied across settings.

Commencement of and Retention in Web-Based Interventions and Response to Prompts and Reminders: Longitudinal Observational Study Based on Two Randomized Controlled Trials

BACKGROUND

Web-based interventions are effective for several psychological problems. However, recruitment, adherence, and missing data are challenges when evaluating these interventions.

OBJECTIVE

This study aimed to describe the use patterns during the commencement phase, possible retention patterns (continuation of data provision), and responses to prompts and reminders among participants in 2 randomized controlled trials (RCTs) evaluating web-based interventions.

METHODS

Data on use patterns logged in 2 RCTs aiming to reduce symptoms of anxiety and depression among adult patients recently diagnosed with cancer (AdultCan RCT) and patients with a recent myocardial infarction (Heart RCT) were analyzed. The web-based intervention in the AdultCan trial consisted of unguided self-help and psychoeducation and that in the Heart trial consisted of therapist-supported cognitive behavioral therapy. In total, 2360 participants' use patterns at first log-in, including data collection at baseline (ie, commencement) and at 2 follow-ups, were analyzed. Both the intervention and comparison groups were analyzed.

RESULTS

At commencement, 70.85% (909/1283) and 86.82% (935/1077) of the participants in AdultCan and Heart RCTs, respectively, logged in and completed baseline data collection after receiving a welcome email with log-in credentials. The median duration of the first log-in was 44 minutes and 38 minutes in AdultCan and Heart RCTs, respectively. Slightly less than half of the participants' first log-ins were completed outside standard office hours. More than 80% (92/114 and 103/111) of the participants in both trials explored the intervention within 2 weeks of being randomized to the treatment group, with a median duration of 7 minutes and 47 minutes in AdultCan and Heart RCTs, respectively. There was a significant association between intervention exploration time during the first 2 weeks and retention in the Heart trial but not in the AdultCan trial. However, the control group was most likely to retain and provide complete follow-up data. Across the 3 time points of data collection explored in this study, the proportion of participants responding to all questionnaires within 1 week from the prompt, without a reminder, varied between 35.45% (413/1165) and 66.3% (112/169). After 2 reminders, up to 97.6% (165/169) of the participants responded.

CONCLUSIONS

Most participants in both RCTs completed the baseline questionnaires within 1 week of receiving the welcome email. Approximately half of them answered questions at baseline data collection outside office hours, suggesting that the time flexibility inherent in web-based interventions contributes to commencement and use. In contrast to what was expected, the intervention groups generally had lower completion rates than the comparison groups. About half of the participants completed the questionnaires without a reminder, but thereafter, reminders contributed to both baseline and follow-up retention, suggesting they were effective. Strategies to increase commencement of and retention in eHealth interventions are important for the future development of effective interventions and relevant research.

ReMindCare, an app for daily clinical practice in patients with first episode psychosis: A pragmatic real-world study protocol

AIM

Despite the potential benefits of e-health interventions for patients with psychosis, the integration of these applications into the clinical workflow and analysis of their long-term effects still face significant challenges. To address these issues, we developed the ReMindCare app. This app aims to improve the treatment quality for patients with psychosis. We chose to study the app in real world and pragmatic manner to ensure results will be generalizable.

METHODS

This is a naturalistic empirical study of patients in a first episode of psychosis programme. The app was purpose-designed based on two previous studies, and it offers the following assessments: (a) three daily questions regarding anxiety, sadness and irritability; and (b) 18 weekly questions about medication adherence, medication side effects, medication attitudes and prodromal symptoms. The app offers preset alerts, reminders and the ability for patients to reach out to their clinicians. Data captured by the app are linked to the electronic medical record of the patient. Patients will use the app as part of their ongoing care for a maximum period of 5 years, and assessments will occur at baseline and at the end of the first, second and fifth years of app use.

RESULTS

Recruitment started in October 2018 and is still ongoing.

CONCLUSIONS

The ReMindCare app represents early real-world use of digital mental health tools that offer direct integration into clinical care. High retention and compliance rates are expected, and this will in turn lead to improved quality of assessments and communication between patients and clinicians.

ReMindCare App for Early Psychosis: Pragmatic Real World Intervention and Usability Study

Background

eHealth interventions are widely used in clinical trials and increasingly in care settings as well; however, their efficacy in real-world contexts remains unknown. ReMindCare is a smartphone app that has been systematically implemented in a first episode of psychosis program (FEPP) for patients with early psychosis since 2018.

Objective

The objective of this study was to assess the efficacy of ReMindCare after 19 months of use in the clinic and varying use by individual patients.

Methods

The integration of the ReMindCare app into the FEPP started in October 2018. Patients with early psychosis self-selected to the app (ReMindCare group) or treatment as usual (TAU group). The outcome variables considered were adherence to the intervention and number of relapses, hospital admissions, and visits to urgent care units. Data from 90 patients with early psychosis were analyzed: 59 in the ReMindCare group and 31 in the TAU group. The mean age of the sample was 32.8 (SD 9.4) years, 73% (66/90) were males, 91% (83/90) were White, and 81% (74/90) were single.

Results

Significant differences between the ReMindCare and TAU groups were found in the number of relapses, hospitalizations, and visits to urgent care units, with each showing benefits for the app. Only 20% (12/59) of patients from the ReMindCare group had a relapse, while 58% (18/31) of the TAU patients had one or more relapses (χ²=13.7, P=.001). Moreover, ReMindCare patients had fewer visits to urgent care units (χ²=7.4, P=.006) and fewer hospitalizations than TAU patients (χ²=4.6, P=.03). The mean of days using the app was 352.2 (SD 191.2; min/max: 18-594), and the mean of engagement was 84.5 (SD 16.04).

Conclusions

To our knowledge, this is the first eHealth intervention that has preliminarily proven its benefits in the real-world treatment of patients with early psychosis.

International Registered Report Identifier (IRRID)

RR2-10.1111/eip.12960

Mobile enhancement of motivation in schizophrenia: A pilot randomized controlled trial of a personalized text message intervention for motivation deficits

OBJECTIVE

Motivation deficits remain an unmet treatment need in schizophrenia. Recent research has identified mechanisms underlying motivation deficits (i.e., impaired effort-cost computations, reduced future reward-value representation maintenance) that may be effective treatment targets to improve motivation. This study tested the feasibility and preliminary effectiveness of Mobile Enhancement of Motivation in Schizophrenia (MEMS), an intervention that leverages mobile technology to target these mechanisms with text messages.

METHOD

Fifty-six participants with a schizophrenia-spectrum disorder were randomized to MEMS (n = 27) or a control condition (n = 29). All participants set recovery goals to complete over 8 weeks. Participants in the MEMS group additionally received personalized, interactive text messages on their personal cellphones each weekday.

RESULTS

Retention and engagement in MEMS were high: 92.6% completed 8 weeks of MEMS, with an 86.1% text message response rate, and 100% reported being satisfied with the text messages. Compared to participants in the control condition, the participants in the MEMS condition had significantly greater improvements in interviewer-rated motivation and anticipatory pleasure and attained significantly more recovery-oriented goals at 8 weeks. There were no significant group differences in purported mechanisms (performance-based effort-cost computations and future reward-value representations) or in self-reported motivation, quality of life, or functioning.

CONCLUSION

Results demonstrate that MEMS is feasible as a brief, low-intensity mobile intervention that could effectively improve some aspects of motivation (i.e., initiation and maintenance of goal-directed behaviors) and recovery goal attainment for those with schizophrenia-spectrum disorders. More work is needed with larger samples and to understand the mechanisms of change in MEMS. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Use of Text Messaging to Improve Clinical Engagement for Individuals With Psychosis: Systematic Review

BACKGROUND

Individuals experiencing psychosis are at a disproportionate risk for premature disengagement from clinical treatment. Barriers to clinical engagement typically result from funding constraints causing limited access to and flexibility in services. Digital strategies, such as SMS text messaging, offer a low-cost alternative to potentially improve engagement. However, little is known about the efficacy of SMS text messaging in psychosis.

OBJECTIVE

This review aimed to address this gap, providing insights into the relationship between SMS text messaging and clinical engagement in the treatment of psychosis.

METHODS

Studies examining SMS text messaging as an engagement strategy in the treatment of psychosis were reviewed. Included studies were published from the year 2000 onward in the English language, with no methodological restrictions, and were identified using 3 core databases and gray literature sources.

RESULTS

Of the 233 studies extracted, 15 were eligible for inclusion. Most studies demonstrated the positive effects of SMS text messaging on dimensions of engagement such as medication adherence, clinic attendance, and therapeutic alliance. Studies examining the feasibility of SMS text messaging interventions found that they are safe, easy to use, and positively received.

CONCLUSIONS

Overall, SMS text messaging is a low-cost, practical method of improving engagement in the treatment of psychosis, although efficacy may vary by symptomology and personal characteristics. Cost-effectiveness and safety considerations were not adequately examined in the studies included. Future studies should consider personalizing SMS text messaging interventions and include cost and safety analyses to appraise readiness for implementation.

mHealth use for non-communicable diseases care in primary health: patients' perspective from rural settings and refugee camps

Background

Non-communicable diseases (NCDs) account for 85% of deaths in Lebanon and contribute to remarkable morbidity and mortality among refugees and underserved populations. This study assesses the perspectives of individuals with hypertension and/or diabetes in rural areas and Palestinian refugee camps towards a population based mHealth intervention called 'eSahha'.

Methods

The study employs a mixed-methods design to evaluate the effectiveness of SMSs on self-reported perceptions of lifestyle modifications. Quantitative data was collected through phone surveys, and qualitative data through focus group discussions. Descriptive statistics and bivariate analysis were performed.

Results

About 93.9% (n = 1000) of respondents perceived the SMSs as useful and easy to read and understand. About 76.9% reported compliance with SMSs through daily behavioral modifications. Women (P = 0.007), people aged ≥76 years (P < 0.001), unemployed individuals (P < 0.001), individuals who only read and write (P < 0.001) or those who are illiterate (P < 0.001) were significantly more likely to receive and not read the SMSs. Behavior change across settings was statistically significant (P < 0.001).

Conclusion

While SMS-based interventions targeting individuals with hypertension and/or diabetes were generally satisfactory among those living in rural areas and Palestinian refugee camps in Lebanon, a more tailored approach for older, illiterate and unemployed individuals is needed.

Keywords

e-health, refugees.

A technology-assisted life of recovery from psychosis

Developments in digital health technologies have the potential to expedite and strengthen the path towards recovery for people with psychosis. This perspective piece provides a snapshot of how a range of digital technologies can be deployed to support a young adult’s efforts to cope with schizophrenia-spectrum illness. In conjunction with a day in the life of this individual, we provide examples of innovations in digital health research designed for this clinical population, as well as brief summaries of the evidence supporting the usability, feasibility, or effectiveness of each approach. From early detection to ongoing symptom management and vocational rehabilitation, this day-in-the-life vignette provides an overview of the ways in which digital health innovations could be used in concert to augment, scaffold, and enhance schizophrenia-spectrum illness management and recovery.

Technological Interventions for Medication Adherence in Adult Mental Health and Substance Use Disorders: A Systematic Review

BACKGROUND

Medication adherence is critical to the effectiveness of psychopharmacologic therapy. Psychiatric disorders present special adherence considerations, notably an altered capacity for decision making and the increased street value of controlled substances. A wide range of interventions designed to improve adherence in mental health and substance use disorders have been studied; recently, many have incorporated information technology (eg, mobile phone apps, electronic pill dispensers, and telehealth). Many intervention components have been studied across different disorders. Furthermore, many interventions incorporate multiple components, making it difficult to evaluate the effect of individual components in isolation.

OBJECTIVE

The aim of this study was to conduct a systematic scoping review to develop a literature-driven, transdiagnostic taxonomic framework of technology-based medication adherence intervention and measurement components used in mental health and substance use disorders.

METHODS

This review was conducted based on a published protocol (PROSPERO: CRD42018067902) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review guidelines. We searched 7 electronic databases: MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, Web of Science, Engineering Village, and ClinicalTrials.gov from January 2000 to September 2018. Overall, 2 reviewers independently conducted title and abstract screens, full-text screens, and data extraction. We included all studies that evaluate populations or individuals with a mental health or substance use disorder and contain at least 1 technology-delivered component (eg, website, mobile phone app, biosensor, or algorithm) designed to improve medication adherence or the measurement thereof. Given the wide variety of studied interventions, populations, and outcomes, we did not conduct a risk of bias assessment or quantitative meta-analysis. We developed a taxonomic framework for intervention classification and applied it to multicomponent interventions across mental health disorders.

RESULTS

The initial search identified 21,749 results; after screening, 127 included studies remained (Cohen kappa: 0.8, 95% CI 0.72-0.87). Major intervention component categories include reminders, support messages, social support engagement, care team contact capabilities, data feedback, psychoeducation, adherence-based psychotherapy, remote care delivery, secure medication storage, and contingency management. Adherence measurement components include self-reports, remote direct visualization, fully automated computer vision algorithms, biosensors, smart pill bottles, ingestible sensors, pill counts, and utilization measures. Intervention modalities include short messaging service, mobile phone apps, websites, and interactive voice response. We provide graphical representations of intervention component categories and an element-wise breakdown of multicomponent interventions.

CONCLUSIONS

Many technology-based medication adherence and monitoring interventions have been studied across psychiatric disease contexts. Interventions that are useful in one psychiatric disorder may be useful in other disorders, and further research is necessary to elucidate the specific effects of individual intervention components. Our framework is directly developed from the substance use disorder and mental health treatment literature and allows for transdiagnostic comparisons and an organized conceptual mapping of interventions.

Perspectives on caregiver-focused MHealth Technologies to improve mental health treatment for low-income youth with ADHD

OBJECTIVE

To examine stakeholder perspectives regarding: (1) whether mobile health (MHealth) tools can improve the mental health (MH) treatment process for low-income youth with ADHD in safety net settings; and (2) what functions would be helpful to improve the treatment process.

METHODS

This study analyzed qualitative data from a larger project that collected information from key stakeholders at four safety-net clinics across Georgia. We conducted five focus groups with caregivers who had a Medicaid-insured child receiving treatment for ADHD, and 17 semi-structured interviews with clinic administrators and providers. Stakeholders shared their perspectives on strategies to improve the MH treatment process, including the use of mHealth tools. Caregivers also completed a brief survey about technology use. We present findings from a thematic analysis of the qualitative data and descriptive findings from the survey.

RESULTS

Participants in each group of stakeholders expressed interest in mHealth tools that would: (1) deliver reminders for caregivers (including appointment and medication refill reminders); (2) help caregivers obtain information about ADHD symptoms and treatment options; (3) help caregivers track information about their child's symptoms and treatment progress; and (4) facilitate communication between caregivers and providers. While more than three-fourths of caregivers had a smartphone, providers and administrators expressed concern that access to mHealth technologies may be inconsistent if low-income families are unable to pay cellular phone bills.

CONCLUSIONS

Caregivers, clinic administrators, and providers were supportive of enhanced mHealth technologies to improve MH care for this population.

Theory-Based Digital Interventions to Improve Asthma Self-Management Outcomes: Systematic Review

BACKGROUND

Asthma is a chronic disease requiring effective self-management to control it and prevent mortality. The use of theory-informed digital interventions promoting asthma self-management is increasing. However, there is limited knowledge concerning how and to what extent psychological theory has been applied to the development of digital interventions, or how using theory impacts outcomes.

OBJECTIVE

The study aimed to examine the use and application of theory in the development of digital interventions to enhance asthma self-management and to evaluate the effectiveness of theory-based interventions in improving adherence, self-management, and clinical outcomes.

METHODS

Electronic databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched systematically using predetermined terms. Additional studies were identified by scanning references within relevant studies. Two researchers screened titles and abstracts against predefined inclusion criteria; a third resolved discrepancies. Full-text review was undertaken for relevant studies. Those meeting inclusion criteria were assessed for risk of bias using the Cochrane Collaboration tool. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study outcomes were classified as medication adherence, self-management, asthma control, clinical markers of health, quality of life, other quality of life outcomes, and health care utilization. Effectiveness was calculated as an average outcome score based on the study's reported significance. The Theory Coding Scheme (TCS) was used to establish the extent to which each intervention had applied theory and which theoretical constructs or behavioral determinants were addressed. Associations between TCS scores and asthma outcomes were described within a narrative synthesis.

RESULTS

Fourteen studies evaluating 14 different digital interventions were included in this review. The most commonly cited theories were Social Cognitive Theory, Health Belief Model, and Self-Efficacy Theory. A greater use of theory in the development of interventions was correlated with effective outcomes (r=.657; P=.01): only the 3 studies that met >60% of the different uses of theory assessed by the TCS were effective on all behavioral and clinical outcomes measured. None of the 11 studies that met ≤60% of the TCS criteria were fully effective; however, 3 interventions were partially effective (ie, the intervention had a significant impact on some, but not all, of the outcomes measured). Most studies lacked detail on the theoretical constructs and how they were applied to the development and application of the intervention.

CONCLUSIONS

These findings suggest that greater use of theory in the development and application of digital self-management interventions for asthma may increase their effectiveness. The application of theory alone may not be enough to yield a successful intervention, and other factors (eg, the context in which the intervention is used) should be considered. A systematic approach to the use of theory to guide the design, selection, and application of intervention techniques is needed.

Is India ready for mental health apps (MHApps)? A quantitative-qualitative exploration of caregivers' perspective on smartphone-based solutions for managing severe mental illnesses in low resource settings

Background

Mobile application based delivery of psycho-social interventions may help reduce the treatment gap for severe mental illnesses (SMIs) and decrease the burden on caregivers. Apps developed in high income settings show effectiveness, but they suffer from lack of applicability in low resource scenarios due to the difference in technology penetration, affordability, and acceptance.

Objective

This study aimed to understand health technology usage, perceived needs, and acceptability of app based interventions in patients with SMIs to improve illness management and reduce caregiver burden.

Methods

The study was conducted in inpatient and outpatient settings of a tertiary care center in North India. A cross-sectional survey assessed smartphone and health app usage. Further, three focus group discussions evaluated the needs and apprehensions in using apps in management of SMIs.

Results

A total of 176 participants including 88 patients and 88 caregivers completed the survey. Smartphone ownership was similar to the national average (30%) in both caregivers (38.6%) and in patients (31.8%). Although subjects regularly used a third party app, health app usage was very low. Cost, unfamiliarity, and language were significant barriers to adoption. The focus group discussions provided insight into the various apprehensions of caregivers in using and in allowing patients to use smartphones and such apps. Caregivers wanted mobile apps for accessing information regarding services and resources available for people with SMI, and they felt such apps can be helpful if they could automate some of their routine caregiving activities. However, the significant difficulty was perceived in regards to the cost of the device, language of the medium, and unfamiliarity in using technology. Apprehensions that SMI patients might misuse technology, or damage the device were also prevalent.

Conclusions

The study systematically looks into the scope, design considerations and limitations of implementing a mobile technology based intervention for low resource settings. With only one-third of the patients and caregivers having access to smartphones and internet, parallel outreach strategies like IVRS should be actively considered while designing interventions. The difficulty of understanding and searching in a non-native language needs to be addressed. Hand holding of caregivers and frequent encouragement from treating doctors might significantly help in technology adoption and in surmounting the apprehensions related to using technology. To make the solution acceptable and useful to the already over-burdened caregivers, developers need to work closely with patients’ family members and follow a ground-up collaborative approach to app development. The scope of delivering mental health services through technology is immense in resource constrained settings like India, provided we, researchers, appreciate and accept the fact that in the varied landscape of a divergent economic, educational, and cultural milieu, a single solution will never suffice for all, and intervention modality matching with end user capacity will be of paramount importance in determining the success of the endeavor.

Differences in the Use and Opinions About New eHealth Technologies Among Patients With Psychosis: Structured Questionnaire

BACKGROUND

Despite a growing interest in the use of technology in order to support the treatment of psychotic disorders, limited knowledge exists about the viability and acceptability of these eHealth interventions in relation to the clinical characteristics of patients.

OBJECTIVE

The objective of this study was to assess the access and use of, as well as experiences and interest in, new technologies using a survey of patients diagnosed with early psychosis compared with a survey of patients diagnosed with chronic psychotic disorders.

METHODS

We designed a structured questionnaire. This questionnaire was divided into five parts: (1) clinical and demographic information, (2) access and use of the internet, (3) use of the internet in relation to mental health, (4) experiences with technology, and (5) patients' interest in eHealth services. In total, 105 patients were recruited from early psychosis units (n=65) and recovery units (n=40).

RESULTS

In this study, 84.8% (89/105) of the patients had access to the internet and 88.6% (93/105) owned an electronic internet device. In total, 71.3% (57/80) of patients who owned a mobile phone were interested in eHealth systems and 38.2% (37/97) reported negative experiences related to the internet usage. We observed differences between the groups in terms of device ownership (P=.02), the frequency of internet access (P<.001), the use of social media (P=.01), and seeking health information (P=.04); the differences were found to be higher in the early psychosis group. No differences were found between the groups in terms of the use of internet in relation to mental health, experiences and opinions about the internet, or interest in eHealth interventions (P=.43).

CONCLUSIONS

The availability and use of technology for the participants in our survey were equivalent to those for the general population. The differences found between the groups in relation to the access or use of technology seemed to due to age-related factors. The use of technology involving mental health and the interest in eHealth interventions were mainly positive and equivalent between the groups. Accordingly, this group of patients is a potential target for the emerging eHealth interventions, regardless of their clinical status. However, 28.7% (23/80) of the studied patients rejected the use of internet interventions and 38.2% (37/97) had unpleasant experiences related to its usage; thus, more in-depth studies are needed to better define the profile of patients with psychosis who may benefit from eHealth treatments.

A randomized study of a smartphone application compared with booklet to improve service user's knowledge of their legal rights

BACKGROUND

The Mental Health Act 2001 has introduced significant changes to the process of admission to hospital for individuals affected by mental health disorders. This study aimed to determine whether a newly designed smartphone application could result in an improvement in service users' knowledge of their rights compared with the paper booklet.

METHODS

This was a randomized study conducted in an outpatient and day-hospital in North Dublin. Participants were randomized to receive the information booklet as either a smartphone application or in the paper form. A questionnaire which was scored from 0 to 10 was devised and was completed at baseline and at 1-week follow-up.

RESULTS

A total of 42 individuals completed the baseline and follow-up questionnaire and of these, 53.7% were female and the mean age was 38.2 years (s.d.±13.5). A total of 34.1% had a diagnosis of a psychotic disorder, 29.3% had a depressive disorder and 22% had bipolar-affective disorder. The mean score before the intervention in the total group was 3.5 (s.d.±2.2) and this increased to 5.8 (s.d.±2.2) at follow-up. Participants randomized to the smartphone application improving by a mean of 2.5 (s.d.±2.5), while those randomized to the booklet improving by a mean of 2.3 (s.d.±2.6), which was not statistically significant.

CONCLUSIONS

Both forms of the information booklet showed improvement in service users' knowledge of their legal rights. It is possible that each individual will have preference for either a paper form or a smartphone form and this study suggests that both forms should be offered to each individual service user.

Use of an android phone application for automated text messages in international settings: A case study in an HIV clinical trial in St. Petersburg, Russia

BACKGROUND/AIMS

Reproducible outcomes in clinical trials depend on adherence to study protocol. Short message service (also known as text message) reminders have been shown to improve clinical trial adherence in the United States and elsewhere. However, due to systematic differences in mobile data plans, languages, and technology, these systems are not easily translated to international settings.

METHODS

To gauge technical capabilities for international projects, we developed SMSMessenger, an automated Android application that uses a US server to send medication reminders to participants in a clinical trial in St. Petersburg, Russia (Zinc for HIV disease among alcohol users-a randomized controlled trial in the Russia Alcohol Research Collaboration on HIV/AIDS cohort). The application is downloaded once onto an Android study phone. When it is time for the text message reminders to be sent, study personnel access the application on a local phone, which in turn accesses the existing clinical trial database hosted on a US web server. The application retrieves a list of participants with the following information: phone number, whether a message should be received at that time, and the appropriate text of the message. The application is capable of storing multiple outgoing messages. With a few clicks, text messages are sent to study participants who can reply directly to the message. Study staff can check the local phone for incoming messages. The SMSMessenger application uses an existing clinical trial database and is able to receive real-time updates. All communications between the application and server are encrypted, and phone numbers are stored in a secure database behind a firewall. No sensitive data are stored on the phone, as outgoing messages are sent through the application and not by messaging features on the phone itself. Messages are sent simultaneously to study participants, which reduces the burden on local study staff. Costs and setup are minimal. The only local requirements are an Android phone and data plan.

CONCLUSION

The SMSMessenger technology could be modified to be applied anywhere in the world, in any language, script, or alphabet, and for many different purposes. The novel application of this existing low-cost technology can improve the usefulness of text messaging in advancing the goals of international clinical trials.

Short Text Messages to Encourage Adherence to Medication and Follow-up for People With Psychosis (Mobile.Net): Randomized Controlled Trial in Finland

Background

A text messaging service (short message service [SMS]) has the potential to target large groups of people with long-term illnesses such as serious mental disorders, who may have difficulty with treatment adherence. Robust research on the impact of mobile technology interventions for these patients remains scarce.

Objective

The main objective of our study was to investigate the impact of individually tailored short text messages on the rate of psychiatric hospital readmissions, health care service use, and clinical outcomes. In addition, we analyzed treatment costs.

Methods

Between September 2011 and November 2012, we randomly assigned 1139 people to a tailored text message intervention (n=569) or usual care (n=570). Participants received semiautomated text messages for up to 12 months or usual care. The primary outcome, based on routinely collected health register data, was patient readmission into a psychiatric hospital during a 12-month follow-up period. Secondary outcomes were related to other service use, coercion, medication, adverse events, satisfaction, social functioning, quality of life, and economic factors (cost analysis).

Results

There was 98.24% (1119/1139) follow-up at 12 months. Tailored mobile telephone text messages did not reduce the rate of hospital admissions (242/563, 43.0% of the SMS group vs 216/556, 38.8% of the control group; relative risk 1.11; 95% CI 0.92-1.33; P=.28), time between hospitalizations (mean difference 7.0 days 95% CI –8.0 to 24.0; P=.37), time spent in a psychiatric hospital during the year (mean difference 2.0 days 95% CI –2.0 to 7.0; P=.35), or other service outcomes. People who received text messages were less disabled, based on Global Assessment Scale scores at the time of their readmission, than those who did not receive text messages (odds ratio 0.68; 95% CI 0.47-0.97; P=.04). The costs of treatment were higher for people in the SMS group than in the control group (mean €10,103 vs €9210, respectively, P<.001).

Conclusions

High-grade routinely collected data can provide clear outcomes for pragmatic randomized trials. SMS messaging tailored with the input of each individual patient did not decrease the rate of psychiatric hospital visits after the 12 months of follow-up. Although there may have been other, more subtle effects, the results of these were not evident in outcomes of agreed importance to clinicians, policymakers, and patients and their families.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 27704027; http://www.isrctn.com/ISRCTN27704027 (Archived by WebCite at http://www.webcitation.org/6rVzZrbuz).

Use of mobile technologies in patients with psychosis: A systematic review

There is a growing interest in mobile Health interventions (m-Health) in patients with psychosis. The aim of this study is to conduct a systematic review in order to analysethe current state of research in this area. The search of articles was carried out following the PRISMA criteria, focusing on those studies that used mobile technologies in patients with psychosis during the period from 1990 to 2016. A total of 20 articles were selected from the 431 studies found. Three types of studies are distinguished: 1) Analysis of quality and usability, 2) Improving treatment adherence and reducing hospital admissions, and 3) Analysisof patient symptoms.

CONCLUSIONS

m-Health interventions are feasible, and are easy to use for patients with psychosis. They evaluate the evolution of psychotic symptoms more efficiently, and improve adherence to treatment, as well as symptoms and hospital admissions. However, a particular strategy does not stand out over the rest, because differences in methodology make them difficult to compare.

Factors Associated With Dropout During Recruitment and Follow-Up Periods of a mHealth-Based Randomized Controlled Trial for Mobile.Net to Encourage Treatment Adherence for People With Serious Mental Health Problems

Background

Clinical trials are the gold standard of evidence-based practice. Still many papers inadequately report methodology in randomized controlled trials (RCTs), particularly for mHealth interventions for people with serious mental health problems. To ensure robust enough evidence, it is important to understand which study phases are the most vulnerable in the field of mental health care.

Objective

We mapped the recruitment and the trial follow-up periods of participants to provide a picture of the dropout predictors from a mHealth-based trial. As an example, we used a mHealth-based multicenter RCT, titled “Mobile.Net,” targeted at people with serious mental health problems.

Methods

Recruitment and follow-up processes of the Mobile.Net trial were monitored and analyzed. Recruitment outcomes were recorded as screened, eligible, consent not asked, refused, and enrolled. Patient engagement was recorded as follow-up outcomes: (1) attrition during short message service (SMS) text message intervention and (2) attrition during the 12-month follow-up period. Multiple regression analysis was used to identify which demographic factors were related to recruitment and retention.

Results

We recruited 1139 patients during a 15-month period. Of 11,530 people screened, 36.31% (n=4186) were eligible. This eligible group tended to be significantly younger (mean 39.2, SD 13.2 years, P<.001) and more often women (2103/4181, 50.30%) than those who were not eligible (age: mean 43.7, SD 14.6 years; women: 3633/6514, 55.78%). At the point when potential participants were asked to give consent, a further 2278 refused. Those who refused were a little older (mean 40.2, SD 13.9 years) than those who agreed to participate (mean 38.3, SD 12.5 years; t1842=3.2, P<.001). We measured the outcomes after 12 months of the SMS text message intervention. Attrition from the SMS text message intervention was 4.8% (27/563). The patient dropout rate after 12 months was 0.36% (4/1123), as discovered from the register data. In all, 3.12% (35/1123) of the participants withdrew from the trial. However, dropout rates from the patient survey (either by paper or telephone interview) were 52.45% (589/1123) and 27.8% (155/558), respectively. Almost all participants (536/563, 95.2%) tolerated the intervention, but those who discontinued were more often women (21/27, 78%; P=.009). Finally, participants’ age (P<.001), gender (P<.001), vocational education (P=.04), and employment status (P<.001) seemed to predict their risk of dropping out from the postal survey.

Conclusions

Patient recruitment and engagement in the 12-month follow-up conducted with a postal survey were the most vulnerable phases in the SMS text message-based trial. People with serious mental health problems may need extra support during the recruitment process and in engaging them in SMS text message-based trials to ensure robust enough evidence for mental health care.

ClinicalTrial

International Standard Randomized Controlled Trial Number (ISRCTN): 27704027; http://www.isrctn.com/ISRCTN27704027 (Archived by WebCite at http://www.webcitation.org/6oHcU2SFp)

Methodology and Reporting of Mobile Heath and Smartphone Application Studies for Schizophrenia

The increasing prevalence of mobile devices among patients of all demographic groups has the potential to transform the ways we diagnose, monitor, treat, and study mental illness. As new tools and technologies emerge, clinicians and researchers are confronted with an increasing array of options both for clinical assessment, through digital capture of the essential behavioral elements of a condition, and for intervention, through formalized treatments, coaching, and other technology-assisted means of patient communication. And yet, as with any new set of tools for the assessment or treatment of a medical condition, establishing and adhering to reporting guidelines-that is, what works and under what conditions-is an essential component of the translational research process. Here, using the recently published World Health Organization mHealth Evaluation, Reporting and Assessment guidelines for evaluating mobile health applications, we review the methodological strengths and weaknesses of existing studies on smartphones and wearables for schizophrenia. While growing evidence supports the feasibility of using mobile tools in severe mental illness, most studies to date failed to adequately report accessibility, interoperability, costs, scalability, replicability, data security, usability testing, or compliance with national guidelines or regulatory statutes. Future research efforts addressing these specific gaps in the literature will help to advance our understanding and to realize the clinical potential of these new tools of psychiatry.

mHealth for Schizophrenia: Patient Engagement With a Mobile Phone Intervention Following Hospital Discharge

BACKGROUND

mHealth interventions that use mobile phones as instruments for illness management are gaining popularity. Research examining mobile phone‒based mHealth programs for people with psychosis has shown that these approaches are feasible, acceptable, and clinically promising. However, most mHealth initiatives involving people with schizophrenia have spanned periods ranging from a few days to several weeks and have typically involved participants who were clinically stable.

OBJECTIVE

Our aim was to evaluate the viability of extended mHealth interventions for people with schizophrenia-spectrum disorders following hospital discharge. Specifically, we set out to examine the following: (1) Can individuals be engaged with a mobile phone intervention program during this high-risk period?, (2) Are age, gender, racial background, or hospitalization history associated with their engagement or persistence in using a mobile phone intervention over time?, and (3) Does engagement differ by characteristics of the mHealth intervention itself (ie, pre-programmed vs on-demand functions)?

METHODS

We examined mHealth intervention use and demographic and clinical predictors of engagement in 342 individuals with schizophrenia-spectrum disorders who were given the FOCUS mobile phone intervention as part of a technology-assisted relapse prevention program during the 6-month high-risk period following hospitalization.

RESULTS

On average, participants engaged with FOCUS for 82% of the weeks they had the mobile phone. People who used FOCUS more often continued using it over longer periods: 44% used the intervention over 5-6 months, on average 4.3 days a week. Gender, race, age, and number of past psychiatric hospitalizations were associated with engagement. Females used FOCUS on average 0.4 more days a week than males. White participants engaged on average 0.7 days more a week than African-Americans and responded to prompts on 0.7 days more a week than Hispanic participants. Younger participants (age 18-29) had 0.4 fewer days of on-demand use a week than individuals who were 30-45 years old and 0.5 fewer days a week than older participants (age 46-60). Participants with fewer past hospitalizations (1-6) engaged on average 0.2 more days a week than those with seven or more. mHealth program functions were associated with engagement. Participants responded to prompts more often than they self-initiated on-demand tools, but both FOCUS functions were used regularly. Both types of intervention use declined over time (on-demand use had a steeper decline). Although mHealth use declined, the majority of individuals used both on-demand and system-prompted functions regularly throughout their participation. Therefore, neither function is extraneous.

CONCLUSIONS

The findings demonstrated that individuals with schizophrenia-spectrum disorders can actively engage with a clinically supported mobile phone intervention for up to 6 months following hospital discharge. mHealth may be useful in reaching a clinical population that is typically difficult to engage during high-risk periods.

Mobile Health for All: Public-Private Partnerships Can Create a New Mental Health Landscape

Research has already demonstrated that different mHealth approaches are feasible, acceptable, and clinically promising for people with mental health problems. With a robust evidence base just over the horizon, now is the time for policy makers, researchers, and the private sector to partner in preparation for the near future. The Lifeline Assistance Program is a useful model to draw from. Created in 1985 by the U.S. Federal Communications Commission (FCC), Lifeline is a nationwide program designed to help eligible low-income individuals obtain home phone and landline services so they can pursue employment, reach help in case of emergency, and access social services and healthcare. In 2005, recognizing the broad shift towards mobile technology and mobile-cellular infrastructure, the FCC expanded the program to include mobile phones and data plans. The FCC provides a base level of federal support, but individual states are responsible for regional implementation, including engagement of commercial mobile phone carriers. Given the high rates of disability and poverty among people with severe mental illness, many are eligible to benefit from Lifeline and research has shown that a large proportion does in fact use this program to obtain a mobile phone and data plan. In the singular area of mobile phone use, the gap between people with severe mental illness and the general population in the U.S. is vanishing. Strategic multi-partner programs will be able to grant access to mHealth for mental health programs to those who will not be able to afford them-arguably, the people who need them the most. Mobile technology manufacturing costs are dropping. Soon all mobile phones in the marketplace, including the more inexpensive devices that are made available through subsidy programs, will have "smart" capabilities (ie, internet connectivity and the capacity to host apps). Programs like Lifeline could be expanded to include mHealth resources that capitalize on "smart" functions, such as secure/encrypted clinical texting programs and mental health monitoring and illness-management apps. Mobile phone hardware and software development companies could be engaged to add mHealth programs as a standard component in the suite of tools that come installed on their mobile phones; thus, in addition to navigation apps, media players, and games, the new Android or iPhone could come with guided relaxation videos, medication reminder systems, and evidence-based self-monitoring and self-management tools. Telecommunication companies could be encouraged to offer mHealth options with their data plans. Operating system updates pushed out by the mobile carrier companies could come with optional mHealth applications for those who elect to download them. In the same manner in which the Lifeline Assistance Program has helped increase access to fundamental opportunities to so many low-income individuals, innovative multi-partner programs have the potential to put mHealth for mental health resources in the hands of millions in the years ahead.