Are we there yet?!-a literature review of recent digital technology advances for the treatment of early psychosis

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

BACKGROUND

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

STUDY DESIGN

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

STUDY RESULTS

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

CONCLUSIONS

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

Developing a process for assessing the safety of a digital mental health intervention and gaining regulatory approval: a case study and academic's guide

BACKGROUND

The field of digital mental health has followed an exponential growth trajectory in recent years. While the evidence base has increased significantly, its adoption within health and care services has been slowed by several challenges, including a lack of knowledge from researchers regarding how to navigate the pathway for mandatory regulatory approval. This paper details the steps that a team must take to achieve the required approvals to carry out a research study using a novel digital mental health intervention. We used a randomised controlled trial of a digital mental health intervention called STOP (Successful Treatment of Paranoia) as a worked example.

METHODS

The methods section explains the two main objectives that are required to achieve regulatory approval (MHRA Notification of No Objection) and the detailed steps involved within each, as carried out for the STOP trial. First, the existing safety of digital mental health interventions must be demonstrated. This can refer to literature reviews, any feasibility/pilot safety data, and requires a risk management plan. Second, a detailed plan to further evaluate the safety of the digital mental health intervention is needed. As part of this we describe the STOP study's development of a framework for categorising adverse events and based on this framework, a tool to collect adverse event data.

RESULTS

We present literature review results, safety-related feasibility study findings and the full risk management plan for STOP, which addressed 26 possible hazards, and included the 6-point scales developed to quantify the probability and severity of typical risks involved when a psychiatric population receives a digital intervention without the direct support of a therapist. We also present an Adverse Event Category Framework for Digital Therapeutic Devices and the Adverse Events Checklist-which assesses 15 different categories of adverse events-that was constructed from this and used in the STOP trial.

CONCLUSIONS

The example shared in this paper serves as a guide for academics and professionals working in the field of digital mental health. It provides insights into the safety assessment requirements of regulatory bodies when a clinical investigation of a digital mental health intervention is proposed. Methods, scales and tools that could easily be adapted for use in other similar research are presented, with the expectation that these will assist other researchers in the field seeking regulatory approval for digital mental health products.

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.

Digitally Enhanced Psychological Assessment and Treatment of Paranoia: A Systematic Review

BACKGROUND

Paranoia is relatively common but can lead to significant distress, impairment and need for care. Digital technologies offer a valuable extension to service provision and are increasingly being integrated into healthcare. This systematic review evaluated feasibility, acceptability, and effectiveness of digitally enhanced psychological assessments and treatments for paranoia across the paranoia continuum (PROSPERO: CRD42023393257).

METHODS

Databases PsychINFO, EMBASE, MEDLINE and Web of Science were searched until 12 June 2023; the Effective Public Health Practice Project (EPHPP) quality assessment tool evaluated studies; and a narrative synthesis was conducted.

RESULTS

Twenty-seven studies met inclusion criteria (n = 3457, 23 assessment and 4 treatment, 2005-2023, most in Europe). Technologies included virtual reality (VR, n = 23), experience sampling methodology (ESM, n = 2), an app (n = 1) and a combination of VR and ESM (n = 1). Assessments involved monitoring paranoia under various virtual conditions or in everyday life. Treatments were generally integrated with Cognitive Behaviour Therapy (CBT), which involved using VR to test out threat beliefs and drop safety behaviours or using an app to support slowing down paranoid thinking. EPHPP ratings were strong (n = 8), moderate (n = 12) and weak (n = 7).

CONCLUSIONS

Digitally enhanced assessments and treatments showed promising acceptability, feasibility and treatment effectiveness. Limitations of studies include small sample sizes, lack of comparison groups and long-term data and limited randomised controlled trials. Results support the potential future integration of VR in the assessment of paranoia and show promise for treatments such as CBT, although further clinical trials are required. Investigation of other technologies is limited.

A systematic review of users experiences of using digital interventions within psychosis: a thematic synthesis of qualitative research

PURPOSE

Although the development of digital mental health support for people with psychosis has been increasing, the development and opportunities to access this have been more limited compared to other mental health conditions. Qualitative research exploring the experiences of using digital interventions amongst people with psychosis is even less well developed; however, such research is crucial in capturing the experiences of using digital interventions to ensure they are meeting the needs of people with psychosis. This paper aimed to synthesise qualitative data related to the experiences of people with psychosis who have used digital interventions.

METHODS

A systematic literature search was conducted of articles published between 1992 and October 2023 using PubMed, MBase, PsycINFO, & OVID Medline. Two reviewers independently reviewed and screened 268 papers. Papers that met inclusion criteria were quality assessed using The Critical Appraisal Skills Programme (CASP) qualitative studies checklist. The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist was used to guide the structure of the report.

RESULTS

A thematic synthesis of 19 studies revealed six overarching themes which related to different aspects and features of the digital interventions: participants' relationship with technology; the accessibility of the interventions; how the interventions could impact on individuals' awareness and management of mental health; enhanced communication and relationships; and opportunities for reflection.

CONCLUSIONS

Benefits of using digital interventions are discussed. Areas for development and improvements are highlighted. Finally, recommendations for stakeholders who develop and implement digital interventions for psychosis are made.

Evaluating remote delivery of cognitive remediation in people with psychosis

BACKGROUND

Cognitive Remediation (CR) is an evidence-based therapy targeting cognitive difficulties in people with psychosis to promote functional recovery, but it is rarely implemented routinely. To reach more individuals, CR is beginning to be delivered remotely, but there is limited evidence to support the acceptability of this method.

AIMS

To evaluate the acceptability and feasibility of remote therapist-supported CR in people with psychosis and estimate its cost and potential benefits.

METHODS

A case-series with all participants assessed before and after therapy with measures of personal goal attainment (main outcome), cognition, functioning and symptoms. Acceptability was assessed with post-therapy interviews. Feasibility was assessed using proportions and confidence intervals on pre-specified parameters. Indication of benefits was assessed with exploratory analyses comparing baseline and post-therapy scores on the pre-specified outcomes. The cost of providing remote CR was assessed from both healthcare and societal perspectives.

RESULTS

Twenty-nine participants started therapy with two dropping out; on average participants attended 25.5 sessions. Interviews suggested that remote CR had good acceptability and led to perceived benefits. Significant and large improvements were observed on goal attainment. Cost analyses suggest that remote CR has the same health care cost as face-to-face therapy but a lower societal cost.

CONCLUSIONS

Our results support the use of remote CR in psychosis services as an alternative delivery modality. This method may improve adherence, attendance and be more convenient for service users. Possible barriers such as poor digital literacy or appropriate device ownership should be addressed before starting therapy.

Blended care in psychosis - A systematic review

Blended-care, a psychosocial intervention combining traditional, face-to-face therapy with digital mental health tools, has shown potential for improving therapeutic processes, fostering patient engagement, and augmenting clinical outcomes. This systematic review aimed to evaluate the development and effectiveness of blended-care interventions tailored for adults diagnosed with schizophrenia-spectrum disorders or other conditions with psychotic features. Our search strategy spanned three electronic databases (PsycINFO, Web of Science, and PubMed) in accordance with the reporting guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We identified 11 papers, each examining the use of one of eight distinct blended-care interventions. Significantly, the majority of these papers (10/11, 91 %) examined these interventions exclusively within controlled research environments, demonstrating both acceptability and favourable impacts on symptomatology and recovery (e.g., 0.22 ≤ Cohen's ds ≤ 1.00). Only one intervention was examined in research settings and real-world conditions, and the shift resulted in low real-world uptake (e.g., only 50 % of practitioners were able to engage at least one of their clients with the intervention) and an inability to reproduce positive changes in clinical outcomes. Additional research is needed to determine the viability of successfully developing and implementing blended-care interventions for psychosis in real-world conditions. An exploration of the developmental processes that could facilitate the transition from research settings to routine clinical practice is vital.

Digital mental health intervention for schizophrenia spectrum and psychotic disorders: Protocol for a pragmatic feasibility study of Horyzons-Canada

Background

Schizophrenia spectrum and other psychotic disorders (SSPD) are among the most debilitating of all mental disorders. While the evidence for psychosocial interventions such as cognitive behavioral therapy and peer support has significantly improved, access to these services remains limited. This paper describes a protocol for a pragmatic feasibility study of a digital mental health intervention (HoryzonsCa) that provides access to evidence-based psychosocial interventions, social networking, and clinical and peer support services through a secured, web-based platform for adults diagnosed with SSPD.

Objective

The objectives are: (1) Adapt and translate HoryzonsCa for implementation in English and French; (2) Develop an implementation and training strategy; (3) Assess the acceptability, safety, and demand of HoryzonsCa; (4) Assess clinical outcomes and perceived impacts; (5) Examine the experiences and process of adapting and implementing HoryzonsCa; (6) Explore the role of sociocultural and demographic factors on HoryzonsCa outcomes and implementation.

Methods

This feasibility study will use a single-group, pre-post, mixed-methods (QUAN-QUAL convergent) research design, with assessments at baseline and 12 weeks. The study aims to recruit 100 individuals (ages 18-50) diagnosed with SSPD from two healthcare settings in Canada. Data collection includes interview-based psychometric measures, self-reports, focus groups, and interviews with participants. The study will also collect qualitative data from moderators and the research team, and will be conducted entirely remotely.

Conclusions

This study has been prospectively registered and is underway. It will provide timely information on the feasibility and potential impacts of using digital mental health services for individuals with chronic mental health conditions.

Trial Registration

ISRCTN12561259; https://doi.org/10.1186/ISRCTN12561259 (250/max 250 words).

Mobile health in the specific management of first-episode psychosis: a systematic literature review

Purpose

The purpose of this systematic literature review is to assess the therapeutic efficacy of mobile health methods in the management of patients with first-episode psychosis (FEP).

Method

The participants are patients with FEP. The interventions are smartphone applications. The studies assess the preliminary efficacy of various types of application.

Results

One study found that monitoring symptoms minimized relapses, visits to A&E and hospital admissions, while one study showed a decrease in positive psychotic symptoms. One study found an improvement in anxiety symptoms and two studies noted an improvement in psychotic symptoms. One study demonstrated its efficacy in helping participants return to studying and employment and one study reported improved motivation.

Conclusion

The studies suggest that mobile applications have potential value in the management of young patients with FEP through the use of various assessment and intervention tools. This systematic review has several limitations due to the lack of randomized controlled studies available in the literature.

Digital health innovation to prevent relapse and support recovery in young people with first-episode psychosis: A pilot study of Horyzons-Canada

Digital health innovations may help to improve access to psychosocial therapy and peer support; however, the existence of evidence-based digital health interventions for individuals recovering from a first-episode psychosis (FEP) remains limited. This study aims to investigate the feasibility, acceptability, safety, and pre-post outcomes of Horyzons-Canada (HoryzonsCa), a Canadian adaptation of a digital mental health intervention consisting of psychosocial interventions, online social networking, and clinical and peer support moderation. Using a convergent mixed-methods research design, we recruited participants from a specialized early intervention clinic for FEP in Montreal, Canada. Twenty-three participants (mean age = 26.8) completed baseline assessments, and 20 completed follow-up assessments after 8 weeks of intervention access. Most participants provided positive feedback on general experience (85%, 17/20) and the utility of Horyzons for identifying their strengths (70%, 14/20). Almost all perceived the platform as easy to use (95%, 19/20) and felt safe using it (90%, 18/20). There were no adverse events related to the intervention. Participants used HoryzonsCa to learn about their illness and how to get better (65%, 13/20), receive support (60%, 12/20), and access social networking (35%, 7/20) and peer support (30%, 6/20). Regarding adoption, 65% (13/20) logged in at least 4 times over 8 weeks. There was a nonsignificant increase in social functioning and no deterioration on the Clinical Global Impression Scale. Overall, HoryzonsCa was feasible to implement and perceived as safe and acceptable. More research is needed with larger sample sizes and using in-depth qualitative methods to better understand the implementation and impact of HoryzonsCa.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

User experiences of an American-adapted moderated online social media platform for first-episode psychosis: Qualitative analysis

Objectives

The current study sought to qualitatively characterize the experiences of American users in a recent open trial of the Horyzons digital platform.

Methods

In total, 20 users on Horyzons USA completed semistructured interviews 12 weeks after their orientation to the platform and addressed questions related to (1) the platform, (2) their online therapist, and (3) the peer workers and community space. A hybrid inductive-deductive coding strategy was used to conduct a thematic analysis of the data (NCT04673851).

Results

The authors identified seven prominent themes that mapped onto the three components of self-determination theory. Features of the platform itself as well as inter- and intra-personal factors supported the autonomous use of Horyzons. Users also reflected that their perceived competence in social settings and in managing mental health was increased by the familiarity, privacy, and perceived safety of the platform and an emphasis on personalized therapeutic content. The behaviors or traits of online therapists as perceived by users and regular contact with peers and peer support specialists satisfied users' need for relatedness and promoted confidence in social settings. Users also described aspects of Horyzons USA that challenged their satisfaction of autonomy, competence, and relatedness, highlighting potential areas for future iterations of the platform's content and interface.

Conclusions

Horyzons USA is a promising digital tool that provides young adults with psychosis with the means to access tailored therapy material on demand and a supportive digital community to aid in the recovery process.

Introducing an implementation framework for augmenting care with digital technology for early psychosis patients: theory and motivation

BACKGROUND

Treatment programs for early-course psychosis are evidence-based interventions that provide specialty care to improve outcomes in patients. Digital technologies offer the potential to augment services and meet the growing demand for care.

AIMS

We introduce a framework to guide the assessment of site readiness for technology and their ability to successfully introduce, implement, and sustain digital technology use. While broader in use that early course psychosis, we focus on this use case to introduce the theory and clinical application.

METHODS

Adapting the replicating effective programs framework, we present an early psychosis focused model. Considering the unique opportunities and challenges of these programs, we present a five-stage evaluation framework. Informed by our clinical experience and recent literature, we present tools and examples to help programs plan and execute successful technology implementation.

RESULTS

The AACCS framework is comprised of five stages: (1) Access (e.g. identifying access to and comfort with technology), (2) Align (e.g. understanding aspects technology can augment), (3) Connect (e.g. customizing technology to stakeholder needs), (4) Care (e.g. implementing technology into treatment), and (5) Sustain (e.g. creating sustainable services). Site visits revealed patients have access to digital tools and are open to implementation into care, while staff prefers digital skills training.

CONCLUSIONS

This framework assists programs in identifying clinical targets to be augmented with technology, stages of implementation, and recommendations for sustaining meaningful technology use.

The role of digital tools in providing youth mental health: results from an international multi-center study

Since the traditional mental health system showed significant limitations in the early identification, diagnosis and treatment of the current new youth psychopathological trajectories, by substantially failing in targeting the needs of the current young generation, there is the demand to redesign and digitally adapt youth mental health care and systems. Indeed, the level of digital literacy and the level of digital competency and knowledge in the field of digital psychiatry is still under-investigated among mental health professionals, particularly in youth mental health. Therefore, we aimed at: (a) carrying out a post-hoc analysis of an international multi-centre study, to investigate the opinions of mental health professionals regarding the feasibility, efficacy and clinical experience in delivering digital mental health interventions (DMHIs) in youths; (b) providing a comprehensive overview on the integrated digitally-based youth mental health care models and innovations. Mental health professionals declared the lack of a formal training in digital psychiatry, particularly in youth mental health. Subjects who received a formal theoretical/practical training on DMHIs displayed a statistical trend towards a positive feasibility of digital psychiatry in youth mental health (p = 0.053) and a perceived increased efficacy of digital psychiatry in youths (p = 0.051). Respondents with higher Digital Psychiatry Opinion (DPO) scores reported a positive perceived feasibility of DMHIs in youths (p < 0.041) and are more prone to deliver DMHIs to young people (p < 0.001). Respondents with higher knowledge scores (KS) declared that DMHIs are more effective in youth mental health (p < 0.001). Overall, the digitalisation indeed allowed young people to keep in touch with a mental health professional, facilitating a more dynamic and fluid mental health care access and monitoring, generally preferred and considered more feasible by post-Millennial youngsters. Accordingly, our findings demonstrated that mental health professionals are more prone to offer DMHIs in youth mental health, particularly whether previously trained and knowledgeable on the topic.

Views of young people with psychosis on using virtual reality assisted therapy. A qualitative study

AIM

Service disengagement is a challenge in young individuals struggling with psychosis. Combining cognitive behavioural therapy for psychosis (CBTp) with virtual reality (VR) has proven acceptable and potentially effective for symptoms and social functioning in adults with psychosis. However, studies focusing on young adolescents are lacking. The aim of the present study was to investigate the acceptability of VR-assisted CBTp among adolescents with psychosis.

METHODS

A qualitative study investigating the acceptability of VR during exposure-based social training among adolescents with early onset psychosis. Thematic analysis was used to identify, analyse, interpret and report patterns from the qualitative interviews.

RESULTS

A total of 27 adolescents with psychosis were invited to participate, 11 declined and 16 were enrolled (59%), and all completed the study. The participants were from 13 until 18 years old, mean age 16 years. None of them had previous experience with use of VR in therapy, but 10 out of 16 participants had prior experience with VR from playing video games. Regarding acceptability, 14 out of 16 had positive expectations towards using VR in CBTp, and they would prefer using VR during exposure-based social training to real-life training only.

CONCLUSIONS

VR-assisted CBTp can be an acceptable intervention for adolescents with psychosis, given their comfort with technology and the opportunity to confront their fears in less threatening virtual social settings with fewer social risks. The present study yields support to continue developing VR-assisted therapy for adolescents, and focusing on VR-interventions for early onset psychosis.

Digital technology for addressing cognitive impairment in recent-onset psychosis: A perspective

Cognitive impairments in psychosis negatively impact functional recovery and quality of life. Existing interventions for improving cognitive impairment in recent-onset psychosis show inconsistent treatment efficacy, small effects, suboptimal engagement and limited generalizability to daily life functioning. In this perspective we explore how digital technology has the potential to address these limitations in order to improve cognitive and functional outcomes in recent-onset psychosis. Computer programs can be used for standardized, automated delivery of cognitive remediation training. Virtual reality provides the opportunity for learning and practicing cognitive skills in real-world scenarios within a virtual environment. Smartphone apps could be used for notification reminders for everyday tasks to compensate for cognitive difficulties. Internet-based technologies can offer psychoeducation and training materials for enhancing cognitive skills. Early findings indicate some forms of digital interventions for cognitive enhancement can be effective, with well-established evidence for human-supported computer-based cognitive remediation in recent-onset psychosis. Emerging evidence regarding virtual reality is favorable for improving social cognition. Overall, blending digital interventions with human support improves engagement and effectiveness. Despite the potential of digital interventions for enhancing cognition in recent-onset psychosis, few studies have been conducted to date. Implementation challenges affecting application of digital technologies for cognitive impairment in recent-onset psychosis are sustained engagement, clinical integration, and lack of quality in the commercial marketplace. Future opportunities lie in including motivational frameworks and behavioral change interventions, increasing service engagement in young people and lived experience involvement in digital intervention development.

Efficacy of Smartphone Apps in Patients With Depressive Disorders: A Systematic Review

BACKGROUND

Digital interventions have become an accessible format in clinical practice to provide better support for patients with mental disorders. However, the clinical efficacy in patients with depressive disorders is not well known. We aimed to determine the efficacy of smartphone applications (apps) in patients diagnosed with a depressive disorder.

METHOD

An electronic database search was performed of PubMed, PsycINFO, and Web of Science, to identify relevant articles up to June 12, 2021. Peer-reviewed articles were screened and selected based on predetermined inclusion and exclusion criteria.

RESULTS

Seven articles met the inclusion criteria and therefore were selected for the systematic review, which included a total of 651 patients. The results were heterogeneous, essentially due to the different methodologies used in the selected studies.

CONCLUSIONS

Digital smartphone-delivered interventions do not appear to reduce depressive symptomatology nor improve the quality of life in patients diagnosed with depressive disorders when compared to an active control group. Taking into account the inherent methodological difficulties and the variability among such studies, it is apparent that further research-with more methodologically refined clinical trials, including larger sample sizes-is needed.

Use of Virtual Reality in Psychiatric Diagnostic Assessments: A Systematic Review

BACKGROUND

Technological developments such as Virtual reality (VR) provide new opportunities to extend and innovate mental healthcare. VR as a tool for clinical assessment has been described as promising, as it can enable real-time assessment within real-like environments or contexts as opposed to self-report and behavioral tasks in laboratory settings.

OBJECTIVE

With this systematic review we aimed to provide an overview of recent studies using VR in the assessment of psychiatric disorders.

METHODS

A systematic search was performed using Pubmed, Embase, PsycInfo, and Web of Science between 2016 and 2020. Studies were included if they used immersive VR, concerned assessment of psychiatric symptoms/disorders, and included adult patients with psychiatric disorders.

RESULTS

The search resulted in 3,163 potentially eligible articles, from which a total of 27 studies fulfilled inclusion criteria. Most studies considered anxiety (n = 7), addictive, (n = 7), or psychotic disorders (n = 5). Regarding ADHD (n = 3), PTSD (n = 3), and pedophilic disorder (n = 1), a few studies had been performed since 2016. The majority of the included studies compared patient groups to healthy control groups.

DISCUSSION

Recent studies on VR-assisted psychiatric assessments have been conducted to validate VR environments, to assess symptoms for diagnostics or therapy goals, search for biomarkers, and to gain knowledge on psychiatric disorders. VR tasks were able to detect some difference between patient and healthy control groups, mainly with regard to self-report measures. Despite previous, promising prospects, the use of VR as a tool in clinical assessments must still be considered as a field in need of continued developments and evaluations.

SYSTEMATIC REVIEW REGISTRATION

www.crd.york.ac.uk/prospero, identifier: CRD42021233772.

Primary Psychosis: Risk and Protective Factors and Early Detection of the Onset

Primary psychosis, which includes schizophrenia and other psychoses not caused by other psychic or physical conditions, has a strong impact worldwide in terms of disability, suffering and costs. Consequently, improvement of strategies to reduce the incidence and to improve the prognosis of this disorder is a current need. The purpose of this work is to review the current scientific literature on the main risk and protective factors of primary psychosis and to examine the main models of prevention, especially those related to the early detection of the onset. The conditions more strongly associated with primary psychosis are socio-demographic and economic factors such as male gender, birth in winter, ethnic minority, immigrant status, and difficult socio-economic conditions while the best-established preventive factors are elevated socio-economic status and an economic well-being. Risk and protective factors may be the targets for primordial, primary, and secondary preventive strategies. Acting on modifiable factors may reduce the incidence of the disorder or postpone its onset, while an early detection of the new cases enables a prompt treatment and a consequential better prognosis. According to this evidence, the study of the determinants of primary psychosis has a pivotal role in designing and promoting preventive policies aimed at reducing the burden of disability and suffering of the disorder.

Digital mental health in China: a systematic review

Mental health problems are highly prevalent in China; however, China's mental health services lack resources to deliver high-quality care to people in need. Digital mental health is a promising solution to this short-fall in view of the population's digital literacy. In this review, we aim to: (i) investigate the effectiveness, acceptability, usability, and safety of digital health technologies (DHTs) for people with mental health problems in China; (ii) critically appraise the literature; and (iii) make recommendations for future research directions. The databases MEDLINE, PsycINFO, EMBASE, Web of Science, CNKI, WANFANG, and VIP were systemically searched for English and Chinese language articles evaluating DHTs for people with mental health problems in mainland China. Eligible studies were systematically reviewed. The heterogeneity of studies included precluded a meta-analysis. In total, 39 articles were retrieved, reporting on 32 DHTs for various mental health problems. Compared with the digital mental health field in the West, the Chinese studies targeted schizophrenia and substance use disorder more often and investigated social anxiety mediated by shame and culturally specific variants, DHTs were rarely developed in a co-production approach, and methodology quality was less rigorous. To our knowledge, this is the first systematic review focused on digital mental health in the Chinese context including studies published in both English and the Chinese language. DHTs were acceptable and usable among Chinese people with mental health problems in general, similar to findings from the West. Due to heterogeneity across studies and a paucity of robust control trial research, conclusions about the efficacy of DHTs are lacking.

Group teletherapy for first-episode psychosis: Piloting its integration with coordinated specialty care during the COVID-19 pandemic

Digital health has emerged in recent years as a tool to optimize care delivery and promote treatment adherence among individuals with first-episode psychosis (FEP). Recent mandates for social distancing and sheltering in place due to the COVID-19 pandemic have catapulted efforts to provide ongoing coordinated specialty care (CSC) on virtual platforms. While prior evidence provides support for the general implementation of virtual individual therapy, there is limited guidance and evidence for the adoption of group teletherapy. Here we describe our efforts to implement group teletherapy for two small cohorts of individuals with FEP receiving care in a coordinated specialty care clinic using methods adopted from Acceptance and Commitment Therapy. We observed high adherence with group visits as well as client satisfaction across groups. Based on our results, we have taken efforts to implement virtual group therapy more permanently in our clinic. Our experience provides guidance and a model for integration of virtual group therapy within CSC. PRACTITIONER POINTS: In-person group therapy can be adapted as an online treatment modality for individuals with first-episode psychosis (FEP). Group teletherapy is both accessible and satisfactory to individuals with FEP. Group teletherapy has potential as a more standard and widespread treatment modality within coordinated specialty care for FEP.

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

Smartphone-delivered self-management for first-episode psychosis: the ARIES feasibility randomised controlled trial

OBJECTIVES

To test the feasibility and acceptability of a randomised controlled trial (RCT) to evaluate a Smartphone-based self-management tool in Early Intervention in Psychosis (EIP) services.

DESIGN

A two-arm unblinded feasibility RCT.

SETTING

Six NHS EIP services in England.

PARTICIPANTS

Adults using EIP services who own an Android Smartphone. Participants were recruited until the recruitment target was met (n=40).

INTERVENTIONS

Participants were randomised with a 1:1 allocation to one of two conditions: (1) treatment as usual from EIP services (TAU) or (2) TAU plus access to My Journey 3 on their own Smartphone. My Journey 3 features a range of self-management components including access to digital recovery and relapse prevention plans, medication tracking and symptom monitoring. My Journey 3 use was at the users' discretion and was supported by EIP service clinicians. Participants had access for a median of 38.1 weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility outcomes included recruitment, follow-up rates and intervention engagement. Participant data on mental health outcomes were collected from clinical records and from research assessments at baseline, 4 months and 12 months.

RESULTS

83% and 75% of participants were retained in the trial at the 4-month and 12-month assessments. All treatment group participants had access to My Journey 3 during the trial, but technical difficulties caused delays in ensuring timely access to the intervention. The median number of My Journey 3 uses was 16.5 (IQR 8.5 to 23) and median total minutes spent using My Journey 3 was 26.8 (IQR 18.3 to 57.3). No serious adverse events were reported.

CONCLUSIONS

Recruitment and retention were feasible. Within a trial context, My Journey 3 could be successfully delivered to adults using EIP services, but with relatively low usage rates. Further evaluation of the intervention in a larger trial may be warranted, but should include attention to implementation.

TRIAL REGISTRATION

ISRCTN10004994.

The Therapeutic Alliance in Digital Mental Health Interventions for Serious Mental Illnesses: Narrative Review

BACKGROUND

Digital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses.

OBJECTIVE

This narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses.

METHODS

A narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance.

RESULTS

Results indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features.

CONCLUSIONS

More research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions.

A Feasibility and Acceptability Trial of Social Cognitive Therapy in Early Psychosis Delivered Through a Virtual World: The VEEP Study

BACKGROUND

Addressing specific social cognitive difficulties is an important target in early psychosis and may help address poor functional outcomes. However, structured interventions using standard therapy settings including groups suffer from difficulties in recruitment and retention.

AIMS

To address these issues, we aimed to modify an existing group social cognitive intervention entitled 'Social Cognition and Interaction Training' (SCIT) to be delivered through a virtual world environment (Second Life ©).

METHODS

A single arm nonrandomized proof-of-concept trial of SCIT-VR was conducted. Five groups of three to five individuals per group were recruited over 6 months. Eight sessions of SCIT-VR therapy were delivered through the virtual world platform Second Life© over a 5-week intervention window. Feasibility was examined using recruitment rates and retention. Acceptability was examined using qualitative methods. Secondary outcomes including social cognitive indices, functioning, and anxiety were measured pre- and postintervention.

RESULTS

The SCIT-VR therapy delivered was feasible (36% consent rate and 73.3% intervention completion rate), acceptable (high overall postsession satisfaction scores) and safe (no serious adverse events), and had high levels of participant satisfaction. Users found the environment immersive. Prepost changes were found in emotion recognition scores and levels of anxiety. There were no signs of clinical deterioration on any of the secondary measures.

CONCLUSION

This proof-of-concept pilot trial suggested that delivering SCIT-VR through a virtual world is feasible and acceptable. There were some changes in prepost outcome measures that suggest the intervention has face validity. There is sufficient evidence to support a larger powered randomized controlled trial.

CLINICAL TRIAL REGISTRATION

ISRCTN, identifier 41443166.

Development of a Lived Experience-Based Digital Resource for a Digitally-Assisted Peer Support Program for Young People Experiencing Psychosis

This paper describes the creation of a web-based digital resource designed for tablet computer use during peer work sessions to structure discussion about recovery in early psychosis. The resource consisted of a series of videos featuring young people who have used early psychosis services discussing how they navigated issues in their own recovery. A participatory process was used to create the resource. Researchers held a series of collaborative development workshops with early psychosis service users, peer workers, other mental health practitioners, and academics. These were used to derive a framework of recovery processes relevant to young people experiencing psychosis, which was considered as useful areas of discussion within a peer work relationship. A semi-structured interview guide based on this framework was then used in video-recorded interviews with young people in recovery from psychosis. Footage was edited into 14 videos and organized into six final themes: My Journey, Self-Care, Connections, My Identity, Life, and Mental Health. The combined expertise of young mental health service users, peer support workers, mental health practitioners, and digital mental health researchers throughout the development process enabled the creation of tailored digital resource for peer work in an early psychosis service.