Feasibility of using a smartphone app to assess early signs, basic symptoms and psychotic symptoms over six months: A preliminary report.

BACKGROUND: Psychosis relapses are common, have profound adverse consequences for patients, and are costly to health services. 'Early signs' have been used to predict relapse, in the hope of prevention or mitigation, with moderate sensitivity and specificity. We investigated the feasibility and validity of adding 'basic symptoms' to conventional early signs and monitoring these using a smartphone app. METHODS: Individuals (n = 18) experiencing a relapse within the past year were asked to use a smartphone app ('ExPRESS') weekly for six months to report early signs, basic symptoms and psychotic symptoms. Above-threshold increases in app-reported psychotic symptoms prompted a telephone interview (PANSS positive items) to assess relapse. RESULTS: Participants completed 65% app assessments and 58% telephone interviews. App items showed high concurrent validity with researcher-rated psychotic symptoms and basic symptoms over six months. There was excellent agreement between telephone call and face-to-face assessed psychotic symptoms. The primary relapse definition, based on telephone assessment and casenotes, compared well with a casenote-only definition but had better specificity. Mixed-effects models provided preliminary evidence of concurrent and predictive validity: early signs and basic symptoms were associated with most app-assessed psychotic symptom variables the same week and with a number of psychotic symptoms variables three weeks later; adding basic symptoms to early signs improved model fit in most of these cases. CONCLUSIONS: This is the first study to test a smartphone app for monitoring early signs and basic symptoms as putative relapse predictors. It demonstrates that weekly app-based monitoring is feasible, valid and acceptable over six months.

Development and Long-Term Acceptability of ExPRESS, a Mobile Phone App to Monitor Basic Symptoms and Early Signs of Psychosis Relapse.

BACKGROUND: Schizophrenia relapses are common, have profound, adverse consequences for patients and are costly to health services. Early signs interventions aim to use warning signs of deterioration to prevent full relapse. Such interventions show promise but could be further developed. This study addresses 2 developments: adding basic symptoms to checklists of conventional early signs and using a mobile phone app ExPRESS to aid early signs monitoring. OBJECTIVE: This study aimed to (1) design a pool of self-report items assessing basic symptoms (Basic Symptoms Checklist, BSC); (2) develop and beta test a mobile phone app (ExPRESS) for monitoring early signs, basic symptoms, and psychotic symptoms; and (3) evaluate the long-term acceptability of ExPRESS via qualitative feedback from participants in a 6-month feasibility study. METHODS: The BSC items and ExPRESS were developed and then adjusted following feedback from beta testers (n=5) with a schizophrenia diagnosis. Individuals (n=18) experiencing a relapse of schizophrenia within the past year were asked to use ExPRESS for 6 months to answer weekly questions about experiences of early signs, basic symptoms, and psychotic symptoms. At the end of follow-up, face-to-face qualitative interviews (n=16; 2 were uncontactable) explored experiences of using ExPRESS. The topic guide sought participants' views on the following a priori themes regarding app acceptability: item content, layout, and wording; app appearance; length and frequency of assessments; worries about app use; how app use fitted with participants' routines; and the app's extra features. Interview transcripts were analyzed using the framework method, which allows examination of both a priori and a posteriori themes, enabling unanticipated aspects of app use experiences to be explored. RESULTS: Participants' mean age was 38 years (range 22-57 years). Responses to a priori topics indicated that long-term use of ExPRESS was acceptable; small changes for future versions of ExPRESS were suggested. A posteriori themes gave further insight into individuals' experiences of using ExPRESS. Some reported finding it more accessible than visits from a clinician, as assessments were more frequent, more anonymous, and did not require the individual to explain their feelings in their own words. Nevertheless, barriers to app use (eg, unfamiliarity with smartphones) were also reported. Despite ExPRESS containing no overtly therapeutic components, some participants found that answering the weekly questions prompted self-reflection, which had therapeutic value for them. CONCLUSIONS: This study suggests that apps are acceptable for long-term symptom monitoring by individuals with a schizophrenia diagnosis across a wide age range. If the potential benefits are understood, patients are generally willing and motivated to use a weekly symptom-monitoring app; most participants in this study were prepared to do so for more than 6 months. TRIAL REGISTRATION: ClinicalTrials.gov NCT03558529; https://clinicaltrials.gov/ct2/show/NCT03558529 (Archived by WebCite at http://www.webcitation.org/70qvtRmZY).

Co-production and evaluation of an e-learning resource to improve African-Caribbean families' knowledge about schizophrenia and engagement with services: a pilot randomised controlled trial protocol.

BACKGROUND: A higher proportion of African-Caribbean people in the UK are diagnosed with schizophrenia spectrum disorders than other ethnic groups. High levels of shame and stigma at individual and community levels contribute to delayed access to care, potentially increasing the duration of untreated psychosis and so worsening outcomes. Inferior access, more coercive care, and worse outcomes have created a 'circle of fear' of mental health services within African-Caribbean communities. This further discourages early engagement with statutory services and increases the burden of care for families living with schizophrenia.Providing tailored and relevant information about psychosis (psychoeducation) has the potential for improving outcomes for patients and families. However, there are no culturally appropriate psychoeducation programmes for African-Caribbeans in the UK. We aim to determine whether an e-learning resource, co-produced with African-Caribbean stakeholders to improve knowledge about psychoses, would be culturally acceptable and accessible to members of this population. METHODS: A pilot randomised controlled trial of the feasibility of co-producing and testing a novel e-learning resource to improve knowledge about and attitudes towards schizophrenia in African-Caribbean families. We will seek to recruit 40 participants, aged ≥ 16 years, either to receive the intervention or as controls. They will self-refer or be referred via inpatient and wellbeing services, family and carers' forums, statutory community mental health teams, and voluntary sector/non-governmental agencies (NGOs). Participants will complete the Ca-KAP, ASMI, and SF-12. Acceptability will be explored qualitatively via focus groups and individual semi-structured interviews. DISCUSSION: The proposed trial will demonstrate the feasibility of conducting a fully powered RCT to evaluate the efficacy of an e-learning resource about schizophrenia with African-Caribbean families. Qualitative work will explore the intervention's accessibility and barriers/facilitators to participation, including attitudes to randomisation. These data will facilitate further refinement of the intervention. TRIAL REGISTRATION: ISRCTN11394005, retrospectively registered 20/03/2018.

Integrating non-drug treatments in early schizophrenia.

There is a range of psychological interventions for established schizophrenia. These include family interventions, motivational interventions for substance misuse and for non-adherence to medication, cognitive remediation for neurocognitive deficits and cognitive-behavioural therapy for symptoms. Psychological interventions may explicitly target risk factors for poor outcome, such as substance use, or protective factors, such as adherence to medication, or be directed at specific symptoms or deficits. There is emerging evidence for efficacy of psychological treatments during, following and even prior to the first episode. Important areas for further study are how different treatment modalities can interact productively, and patient and carer preferences for treatment. Many trials of psychological treatments have design flaws and this tends to overestimate the treatment effect.

The evolution of symptoms in the early course of non-affective psychosis.

Most previous studies investigating the factor structure of psychosis have focussed on chronic samples. First episode samples with longitudinal follow up are few. To investigate the stability and validity of symptom factors, a sample of 257 patients with DSM IV nonaffective psychoses were assessed using the PANSS during the acute first episode and at 3- and 18-month follow up. Exploratory factor analysis of the changes in PANSS item scores over time gave a five-factor solution. This was consistent with the solutions to factor analyses at the initial assessment and each of the follow-ups. However, there was progression over follow-up. Confirmatory factor analysis demonstrated that symptom ratings at 18-month follow-up fitted the models from existing research, in relatively chronic samples, better than the ratings at the initial assessment. A psychomotor poverty factor showed most stability over time and a positive symptom factor most change. Factors showed different associations with demographic and external variables, further supporting their validity.

Insight and neurocognition in schizophrenia.

The relationship between neurocognitive impairments in schizophrenia remains unclear. Recent literature was reviewed and the most consistent finding was an association between perseverative errors on the Wisconsin Card Sort Test (WCST) and poor insight. The aim was to confirm and extend this finding using a range of assessments relevant to perseveration, and different dimensions of insight, in a sample of 33 acutely psychotic subjects within 5 years of onset of schizophrenia and related disorders. Results showed a correlation (r=-0.59) between insight and perseverative errors, rather than more general measures of abstraction. A factor representing relabelling symptoms, derived from insight scale items, correlated even more strongly; however, other insight factors correlated more weakly, suggesting they are less dependent on neuropsychological deficits. The ability to monitor output and correct errors appears to be closely related to the core features of insight in psychosis.