In 2020, nearly 8 billion mobile phone subscriptions were recorded worldwide (Ericsson Mobility Report, 2020) and this is only predicted to grow. With this technology at so many people’s fingertips, there has been growing interest in Mobile Health (mHealth), which refers to the use of mobile phone technologies to improve public health and healthcare (Free, et al., 2010).
mHealth has been proposed as a useful technology for a wide spectrum of mental health conditions, such as affective disorders and schizophrenia (Berrouiguet, et al., 2016).
mHealth works for mental health by targeting medication adherence, self-monitoring symptoms, and identifying signs of relapse (Firth, et al., 2016). High rates of relapse are associated with poorer quality of life (Briggs et al., 2008) increased likelihood of long-lasting symptoms (Shepherd et al., 1989), and greater social impairment (Hogarty et al., 1991). Thus, using mHealth to target conditions like schizophrenia and schizoaffective disorder (SAD) where 5-year relapse rates can be as high as 82% (Robinson et al., 1999) is particularly useful.
Various attempts have been made to apply mHealth interventions in the treatment of schizophrenia and SAD, however, these were lacking in collaboration from people with lived experience of schizophrenia and SAD, and that is where the T4RP programme by Cullen et al. (2020) comes in.
The Texting for Relapse Prevention Program (T4RP) is one of these interactive mHealth interventions targeting people with schizophrenia and SAD who use text messages. It is tailored to every enrolled individual and works by sending them daily texts asking about their top five warning symptoms of relapse, which have been customised by the participants themselves. The individual replies with a short answer and receives follow-up texts with specific suggestions or a supportive message, depending on whether the symptom was present or not. They also receive an additional daily text related to their medication or an inspirational quotation. If patients text back on multiple days “yes” to experiencing symptoms, their provider is notified, who will either: (a) discuss the patient’s case with a team of professionals, (b) look at reviewing medication, or (c) try and address social and/or environmental stressors.
Patients, providers, and administrators were involved in the T4RP development and Cullen and collaborators (2020) piloted it for 6 months using a randomised-controlled trial. The aim was to assess its feasibility and acceptability. Participants were patients with a schizophrenia or SAD diagnosis attending a community psychiatry programme. They were clinically assessed at baseline, then randomly allocated to either the control or intervention group and assessed at 3 and 6 months from enrolment. To evaluate the effectiveness of the T4RP programme, participants were given questionnaires about relapse, recovery, institutionalisations, medication adherence, patient empowerment, and patient-provider communication.
The authors hypothesised that the T4RP would promote recovery and reduce rates of relapse by promoting self-management of early relapse symptoms, medication adherence, and improving patient-provider communication.
As the current study was a pilot study, the authors determined that an appropriate alpha level for the statistical analyses was 0.2.
- The study found that participants who were enrolled on the T4RP showed significantly lower levels of positive symptoms compared to those who were not at baseline and at 6 months follow-up.
- No differences were indicated between participants enrolled and those not enrolled in the programme in regards to hospital visits and communication with service-providers.
- However, participants receiving the T4RP intervention showed significantly improved injectable medication adherence both at baseline and at 6-month follow-up, while also experiencing improvements in patient empowerment.
- While levels of recovery seemed to be better for those on the programme, the differences between the two groups of participants were not seen six months after the intervention.
Despite the fact that differences were not observed across all factors targeted by the researchers, the decline in positive symptoms and the improvement in medication adherence, as well as patient empowerment, highlights the potential for the T4RP intervention to be a useful and effective intervention for people with schizophrenia and SAD to identify early signs of relapse.
Strengths and limitations
One strength of the current study is the investigation and evaluation of a text-message based intervention and its acceptability and feasibility for people with schizophrenia and schizoaffective disorder. Unlike many recent self-help apps that require users to have at least a smartphone, texting is a function that even older phone models have, which can potentially increase the number of users this intervention could be used by. Furthermore, T4RP was developed with input from people with lived experience of schizophrenia or SAD. Patient and public involvement (PPI) is highly recommended by the National Institute for Health Research (NIHR) and has shown to improve information for patients, improving access to services and setting up new services (Crawford et al, 2002).
However, several areas of the study could be improved upon. The largest issue would be the alpha level. The “alpha level” was set to 0.20, meaning that there is a 20% chance that the findings observed could be due to type 1 error. The authors justified the use of a larger p-value by aiming to assess the intervention in terms of “feasibility and acceptability”. However, the concepts of feasibility and acceptability were not adequately explored. It may have been more appropriate to investigate these by using a qualitative approach, such as asking participants which parts of the T4RP they found suitable or whether the intervention was user-friendly. Incorporating service user perspectives into the development of T4RP could make the program longer lasting, especially when text-messaging-based interventions are relatively novel in mHealth.
A further limitation of the study is the sample used. The total sample amounted to only 40 participants, of which, 34 were of Black/African American descent. The small sample and lack of variation in ethnicity raise the question of whether these findings are generalisable to the wider target population. Furthermore, all participants were recruited from the same hospital-based community psychiatry programme, limiting the sample by geographical location. The paper states that a small sample is acceptable for investigating feasibility and acceptability, although due to their focus on efficacy a larger and less homogenous sample would have been more beneficial in order to avoid potential selection bias.
Implications for practice
This study suggests that the use of text messaging may be able to help people with positive symptoms, medication adherence, and patient empowerment. To the authors’ knowledge, T4RP is the first text messaging-based programme with significant input from service users. Future research should continue to incorporate patients and participants to understand better how the T4RP works.
T4RP shows potential as a digital intervention as it is low-cost and easily implemented. However, we feel we cannot yet comment on whether the T4RP intervention is clinically effective. Had the present study examined feasibility and acceptability, this research would have provided an example of the benefits of technology by harnessing its functionality. The study opens avenues for research on other possible technologies, such as artificial intelligence, smartphone apps, and virtual reality and are exciting prospects, but they still require rigorous testing and refinement to see how they can be effectively integrated into existing psychological concepts for improving well-being.
Statement of interests
None to declare.
Thanks to the UCL Mental Health MSc students who wrote this blog from Rowe B Group: Annabelle Durrad (@AnnabelleDurr4d), Davin Schmidt (@DavinSchmittlez), Cristina Vasquez (@cristinavasqb), Duncan Lim, Insia Khan, Ella Mather (@EllaMather5) and Manuela Uribe.
UCL MSc in Mental Health Studies
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Cullen, B. A., Rodriguez, K, Eaton, W. W., Mojtabai, R., Von Mach, T., & Ybarra, M. L. (2020). Clinical outcomes from the texting for relapse prevention (T4RP) in schizophrenia and schizoaffective disorder study. Psychiatry Research, 292, 113346
Ericsson Mobility Report. (2020). Ericsson Mobility Report. Retrieved from https://www.ericsson.com/4adc87/assets/local/mobility-report/documents/2020/november-2020-ericsson-mobility-report.pdf
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