Over the past few months with the Covid-19 pandemic, traditional ways of working have been disrupted. This has been no different for mental health services, which have needed to adapt to remote ways of providing support to enable individuals to self-manage their symptoms and avoid relapse independently. These events combined with the increase in availability of digital technology such as smartphones in recent years, has shifted attention to digital health interventions (DHI) for mental health conditions that can be provided outside of traditional primary care. Digital technologies are found to support people with ‘severe mental illness’ to enable self-care, improve clinical services and provide peer support, which in combination may reduce high mortality rates for this group (Gega, 2019).
The focus of the current study was a DHI for individuals who experienced a first episode of psychosis (FEP), characterised by symptoms such as hearing voices and experiencing paranoia, which can interfere with daily functioning, relationships and cause high levels of distress. In England, Early Intervention in Psychosis (EIP) teams aim to support individuals for a period of 3 years with medication support and access to psychosocial interventions (Shields, 2016). However, following discharge, relapse and the need for continued support from mental health services is common (Puntis et al, 2018), which suggests those experiencing FEP have additional support needs not being met by the current format of EIP services.
In terms of existing apps for psychosis specifically, the evidence is still in the early stages. The current study identifies one previous trial of a smartphone app for EIP clients, a proof of concept trial of a self-management app ‘Actissist’ (Bucci et al, 2018); a CBT informed app featuring self-assessment exercises and subsequent information and coping strategies. This study reported benefits in the intervention group with mood and general and negative symptoms post-treatment in comparison to control participants. A larger scale trial of this app is currently underway.
The authors of the current study conducted a feasibility RCT, which compared the ‘My journey 3’ app with Treatment as Usual (TAU), to investigate the acceptability and feasibility of integrating the app into EIP services. My journey 3 was developed to fulfil basic tasks people would like in EIP for self-management, including recognising early warning signs, recognising and monitoring symptoms, and creating plans for their recovery.
Development of My Journey 3
My Journey 3 was designed to be used both independently by individuals experiencing FEP and with support from staff in EIP services. The app’s content was produced collaboratively between researchers, digital health experts, EIP service staff and service users.
My journey 3 is comprised of five key sections
- My recovery plan; set recovery goals, list actions to promote well-being, set reminders to encourage engagement in these activities
- Relapse prevention plan; identify and list triggers, early warning signs of relapse and personalised coping strategies, create a crisis plan
- Symptom monitoring; presented with seventeen different symptoms and behaviours with follow-up questions to rate severity and frequency of any experienced
- Medication tracker; set daily alerts to log medication use
- Information sheets; psychoeducation on mental health, medication and mental health services
The authors conducted an unblended feasibility RCT which compared a supported self-management Smartphone app (My Journey 3) + Treatment as Usual (TAU), with a control group receiving TAU only. The study ran for 12 months across 6 EIP services in 3 NHS trusts.
- At least 1 episode of psychosis
- Currently on EIP service caseload
- Owned smartphone.
Participants were randomly allocated (1:1 ratio) to the intervention or control groups. Those in the intervention group received the My Journey 3 app and attended individual training sessions with a researcher on how to navigate and use the app. Researchers recommended using the app at least once a week, but participants were advised their level of engagement was up to them.
The main outcome (relapse of psychosis) was assessed by accessing patient records to identify any admissions to acute mental health services during the 12-month trial period. Additional outcome measures were assessed by a range of self-report measures and clinical structured interviews at baseline, 4 months and 12 months. Usage data from My Journey 3 was used to assess acceptability of and engagement with the intervention. An additional assessment of acceptability was conducted through qualitative semi-structured interviews at 4 months with intervention participants and staff.
Overall, 40 participants were included, 20 in the intervention group and 20 who received TAU. The authors reported attrition rates to be low; 75% at both follow ups. The sample was predominantly male (70%) with a mean age of 29.7, reported to be similar to standard caseloads of EIP services. Participant engagement with the app varied, with a small proportion showing frequent engagement and a median usage of 16.5 times across the study period.
For participant outcomes from analysis of effect sizes and confidence intervals, no differences between intervention and control group were identified at either follow-up time point. However, as this was a feasibility trial the sample lacked sufficient power to identify intervention effect.
For the main outcome measure (relapse) during the study 5 participants relapsed (3 intervention, 2 control) with no significant difference between the groups (however again, the study did not have sufficient power to assess this).
From qualitative interviews, most participants reported the app was acceptable and a number reported benefits from use. Barriers that emerged from the interviews included concerns around lack of clinician support and data privacy. Additionally, from clinician points of view, lack of time available to support participants regularly with the app was identified as a barrier.
The study demonstrates through low attrition rates that recruitment and retention in an RCT evaluating My Journey 3 is feasible, and the intervention is deliverable in EIP services.
Due to varied levels of participant engagement with the app, it is unclear whether sufficient time was spent using My Journey 3 for useful self-management activities, e.g. detailed monitoring of symptoms to occur. If engagement issues could not be overcome it would raise the question as to whether further study and roll out is appropriate.
Strengths and limitations
- My Journey 3 was developed with collaborative input from a range of stakeholders including views and opinions of service users
- Following the feasibility study, no severe adverse events were recorded from people using the app, which suggests it could be safe.
- Inclusion criteria (ownership of Android smartphone) may limit representativeness of the sample to the EIP service user population
- The researchers conducting follow-up interviews were not blind to participant allocation, which may have introduced bias or inflation of observed effects related to outcome measures
- The control group received TAU rather than an active control, therefore the study did not control for non-specific effects of smartphone use.
Implications for practice
In an increasingly digital world and with the impact of the Covid-19 pandemic on ways of working and access to face to face mental health support, the case for the role of digital mental health interventions is strengthened.
As with other studies of DHI for mental health conditions, the low level of app use in the current study identifies the need to explore further facilitators of engagement. An increase in the role of clinicians for supporting implementation and encouraging use of the DHI may have the potential to increase engagement.
Following the feasibility study, the authors discuss whether relapse was an effective outcome measure and whether (for a future large scale RCT) assessing symptom severity or patient-valued outcomes may be more appropriate.
Statement of interests
Rosa Pitts was previously a Research Assistant on the Actissist trial until August 2020.
Steare, T., O’Hanlon, P., Eskinazi, M., Osborn, D., Lloyd-Evans, B., Jones, R., … & Johnson, S. (2020). Smartphone-delivered self-management for first-episode psychosis: the ARIES feasibility randomised controlled trial. BMJ open, 10(8), e034927.
Bucci, S., Barrowclough, C., Ainsworth, J., Machin, M., Morris, R., Berry, K., … & Haddock, G. (2018). Actissist: proof-of-concept trial of a theory-driven digital intervention for psychosis. Schizophrenia bulletin, 44(5), 1070-1080.
Gega L. How can digital technology help close the mortality gap for people with severe mental illness? The Mental Elf, 23 May 2019.
Puntis, S., Oke, J., & Lennox, B. (2018). Discharge pathways and relapse following treatment from early intervention in psychosis services. BJPsych open, 4(5), 368-374.
Shields G. Early intervention in psychosis services: better outcomes, improved costs. The Mental Elf, 21 Dec 2016.