Web-based psychoeducation

Several web-based psychoeducation interventions have been developed for psychosis. It is an emerging field, with few high-quality studies, but systematic reviews have concluded that web-based psychoeducation about psychosis is feasible, acceptable and potentially effective for people of various ages and stages of illness (Reference Välimäki, Hätönen and LahtiVälimäki 2012; Reference Alvarez-Jimenez, Alcazar-Corcoles and Gonzalez-BlanchAlvarez-Jimenez 2014; Reference Van der Krieke, Wunderink and Emerenciavan der Krieke 2014). Challenges include engagement with self-guided interventions, which is also a problem in evaluations of unsupported web-based interventions for common mental health problems (Reference Kaltenthaler, Parry and BeverleyKaltenthaler 2008).

In in-patient settings, web-based psychoeducation packages could support patients’ self-management skills and nurses’ psychoeducation skills, and facilitate greater consistency of treatment across settings. A feasibility study in which participants on an acute in-patient ward used the website MieliNet (Box 2) with nurse support found that 75% of the sessions were completed (Reference Anttila, Välimäki and HätönenAnttila 2012). However, patients’ mental state and level of insight, and patients’ and nurses’ IT skills affected completion rates, indicating that although the majority of acutely unwell patients were able to use the intervention, computerised interventions may not be acceptable for all.

In community settings, computerised interventions could facilitate increased access to recommended psychosocial interventions and greater user choice and control over when and where they receive it. A small pilot RCT of a family intervention using the SOAR website (Box 2) delivered in patients’ homes with minimal therapist input reported high engagement with the intervention, and significant improvements in positive symptoms and knowledge about schizophrenia compared with usual care (Reference Rotundi, Anderson and HaasRotundi 2010). HORYZONS, a web-based relapse prevention intervention for patients with first-episode psychosis (Box 2), was found to be acceptable, feasible and safe when delivered to young people with little clinician support in an open trial, although only 20% of participants completed at least five of seven psychoeducation modules (Reference Alvarez-Jimenez, Bendall and LedermanAlvarez-Jimenez 2013).

Computerised CBT

Cognitive–behavioural therapy for psychosis (CBT-P) targets negative appraisals of psychotic experiences in order to reduce associated distress and improve functioning. The National Institute for Health and Care Excellence (NICE) recommends access to CBT-P for everyone with a schizophrenia spectrum diagnosis, but current provision is poor (Reference Haddock, Eisner and BooneHaddock 2014). Low-intensity CBT interventions may help to close this gap, although we found just one evaluation of a web-based CBT-P intervention. In a small open study, Coping with Voices (Box 2) was found to be acceptable and feasible for adults when delivered without support in a mental health setting, and significant pre–post reduction in voice severity was observed for those who completed the intervention (Reference Gottlieb, Harper Romeo and PennGottlieb 2013). However, only 25% of participants reported following through with homework assignments. A larger trial is underway (see http://cpr.bu.edu/research/current-research/coping-with-voices).

Computer-assisted cognitive remediation therapy

Cognitive remediation therapy (CRT) is a behavioural-training-based intervention targeting cognitive deficit. It aims to enhance cognitive processes (attention, memory, executive function, social cognition and metacognition), with the ultimate goal of functional rehabilitation, and has been found to be modestly effective (Reference Wykes, Huddy and CellardWykes 2011). CRT traditionally involved manual tasks, but computer-based training has also been used since the 1990s. The use of computer software allows unlimited task repetitions, a variety of forms of reinforcement, accurate and instantaneous feedback, automatic adjustment of difficulty level based on performance (Reference Grynszpan, Perbal and PelissoloGrynszpan 2011), and personalised yet standardised treatment. Computer-assisted cognitive remediation therapy (CACRT) has the most established evidence base of any intervention for psychosis using IT: meta-analyses have found similar magnitudes of effect to manualised CRT (Reference Grynszpan, Perbal and PelissoloGrynszpan 2011).

Traditionally, CRT involves multiple repetitions of abstract cognitive tasks, which can be tedious and require adjunctive rehabilitative work to generalise the benefits of training to improvements in daily functioning (Reference Reeder, Pile and CrawfordReeder 2016). A new computerised CRT package, CIRCuiTS, is designed to enable this skills transfer to take place within the training program itself, through the use of both abstract tasks and simulated activities of daily living (e.g. food shopping) in a virtual village environment. Results of early feasibility testing suggest that this format is highly acceptable to users (Reference Reeder, Pile and CrawfordReeder 2016).

Although the majority of CRTs (whether computer-assisted or not) involve considerable face-to-face contact, the possibilities afforded by computerised training packages may enable more cost-effective interventions, through reducing the therapist time and expertise required to deliver them. Professor Til Wykes and colleagues are currently exploring the web-based CIRCuiTS package in a clinical setting with health worker support; exact requirements for therapist time and skill are yet to be determined (T. Wykes, interview with P. O'H, 2015).

Apps

Evidence suggests that people with psychosis increasingly own smartphones (Reference Firth, Cotter and TorousFirth 2016). As in the general population, ownership seems to be higher among younger people, with reports of around 69% of patients with first-episode psychosis owning an internet-enabled mobile device (Reference Lal, Dell'Elce and TucciLal 2015). More akin to a computer than their mobile phone predecessors, but usually carried on the person, smartphones provide a promising way of assessing need for support in real time and delivering timely, interactive interventions – making use of web-based resources, audio/visual content and other functionality – as people go about their everyday lives (Reference Danaher, Brendryen and SeeleyDanaher 2015). Although there is currently little empirical evidence to support their implementation, several apps for psychosis have been developed (Box 3), and results from five studies of four smartphone apps suggest that they are acceptable and feasible (Reference Firth and TorousFirth 2015).

Smartphone intervention delivery may be particularly helpful for people with psychosis, since cognitive impairment and motivational difficulties may limit the ability to remember, initiate and maintain strategies learned in therapy sessions. To the best of our knowledge, the FOCUS app (Box 3) is the only psychosocial app intervention to have been evaluated to date. In an open trial, patients reported feeling confident, comfortable and satisfied with the FOCUS app, and usage was high – 5 times per day on average. Significant reductions were found on scores for depression and positive symptoms of schizophrenia after using the app for 1 month (Reference Ben-Zeev, Brenner and BegaleBen-Zeev 2014b). Ben-Zeev and colleagues are now conducting a large RCT (trial identifier: NCT02421965) comparing FOCUS with clinic-based self-management for adults with serious mental illness. A CBT-informed app for patients with first-episode psychosis, Actissist (Box 3), is also currently being evaluated in an RCT (Reference Bucci, Barrowclough and AinsworthBucci 2015).

Smartphone apps might also be used to enhance automated intervention models. Self-reporting of psychotic symptoms via ClinTouch (Box 3) not only produces clinically meaningful data, but also seems to increase adherence compared with SMS methods (Reference Ainsworth, Palmier-Claus and MachAinsworth 2013). A trial is currently underway (trial identifier: ISRCTN88145142; chief investigator: Dr Eve Applegate) of an automated system using ClinTouch that alerts both patients and their clinical team in real time to indications of relapse in order to prompt early intervention.

Qualitative data from the ClinTouch studies suggest that some patients find the regular reporting of symptoms to be repetitive, which may lead to disengagement in the longer term (Reference Palmier-Claus, Rogers and AinsworthPalmier-Claus 2013). Researchers are currently investigating whether passive monitoring of indicators of psychotic relapse using the sensor technologies increasingly embedded in smartphones (e.g. accelerometers, the Global Positioning System (GPS), microphones) may be more acceptable to users and more sensitive to change than self-report. The Crosscheck system is currently being developed and tested to detect patterns in paralinguistic voice properties, physical activity, location, sleep patterns, mood and psychotic symptoms, and to generate personalised early warning models (trial identifier: NCT01952041; princial investigator: Dr Dror Ben-Zeev). An early prototype of the system seems to be acceptable to participants with psychosis, although the research team note that self-selection is likely, with those who are concerned about this type of monitoring choosing not to take part in testing (Reference Danaher, Brendryen and SeeleyD. Ben-Zeev, interview with G. A.-A., 2015). If successful, Crosscheck could be used to flag up potential relapse and prompt an early intervention response in a similar way to ClinTouch and ITAREPS.

Smartphone apps might also tackle the prevalence of obesity and cardiometabolic disorders among people with psychosis (which is twice that in the general population (Reference Osborn, Wright and LevyOsborn 2008)). In the general population, fitness apps are growing in popularity more than any other app category (Reference KhalafKhalaf 2014), and results from three small feasibility studies of fitness apps for people with serious mental illness are promising (Reference Naslund, Marsch and McHugoNaslund 2015).

Therapeutic serious games

Serious games are video games with a primary purpose other than pure entertainment. Their potential lies in their ability to increase engagement with treatment that is painful (e.g. chemotherapy) or boring (e.g. repetitive rehabilitation tasks) (Reference KatoKato 2010). Techniques that have been successful in engaging people in commercial games – including daily ‘quests’ and reward systems such as ‘boosters’ or extra lives – could be used to increase adherence to e-interventions for psychosis. Serious games designed for physical health complaints have shown promise (Reference KatoKato 2010).

In psychosis, gaming techniques might enhance motivation to complete repetitive tasks targeting cognition (Reference Chan, Ngai and LeungChan 2010). A study of cognitive training for adults with schizophrenia or schizoaffective disorder found that creating a personalised fantasy gaming context for training tasks led to greater intrinsic motivation to complete the tasks, improved attention and enhanced task-related learning (Reference Chan, Ngai and LeungChan 2010). Bias Buster, a recently developed serious game for patients with first-episode psychosis, is currently under investigation in an RCT (Reference Lal, Dell'Elce and TucciL. van der Krieke, interview with G. A.-A., 2015). In this version of a popular commercial game, the user earns bonuses by completing repetitive cognitive bias modification (CBM) computer tasks. CBM has shown promise in targeting cognitive biases implicated in the development of psychosis (Reference Steel, Wykes and RuddleSteel 2010), but engagement has been identified as a potential challenge. Bias Buster was found to be acceptable to a small sample of patients with first-episode psychosis, although it fell short of their expectations of a video game (Reference Wartena, van Dijk, Schouten, Fedtke and BekkerWartena 2013). More investigation is needed into how to present serious games to people with psychosis, as well as which psychosocial approaches they might add value to and for whom.

Virtual and augmented reality

Virtual reality

Virtual reality gives a sense of being immersed and present in, and interacting with, a three-dimensional world. This experience can elicit similar psychological and physiological responses to the real world. VR technology seems to be acceptable, safe and engaging for people with psychosis (Reference Macedo, Marques and QuierosMacedo 2014), and potential applications in assessment and treatment are beginning to be explored (Reference FreemanFreeman 2008).

The immersive nature of VR experiences offers opportunities for therapeutic learning, skills practice and confidence-building in a low-threat environment for people with psychosis for whom perceived threat or hospital admission make real-world encounters difficult. Social skills training using VR role-play may enhance motivation and lead to greater improvements in conversational and assertiveness skills than traditional role-play (Reference Park, Ku and ChoiPark 2011). The participant wears a head-mounted display and a position tracker, and has the experience of being immersed in a virtual environment (e.g. a coffee shop) through their own avatar, and interacting with other avatars, who give corrective feedback according to the person's interaction during a conversation role-play.

VR technology might also enhance cognitive behavioural interventions for psychosis (Reference FreemanFreeman 2008). Behavioural experiments that challenge threat beliefs are considered an essential component of CBT for psychosis, but can be unacceptably daunting for patients in real-world contexts. Professor Daniel Freeman is currently undertaking a small exploratory RCT of a VR intervention for paranoia, and reports indications of positive outcomes (D. Freeman, interview with P. O'H, 2015).

VR has recently been used in the development of AVATAR therapy. People who are able to have dialogues with their voices feel more in control and less helpless than those who are not, but establishing a dialogue with an entity you cannot see presents particular challenges (Reference Leff, Williams and HuckvaleLeff 2014). In AVATAR therapy, participants are able to create a virtual embodiment of their voice (Fig. 1). A therapist both speaks through the avatar, and provides encouragement for the individual to engage in a dialogue with it. AVATAR therapy aims to enable the individual to learn to gain control over the avatar, with the intention that they will generalise this experience to their persecutory voice.

FIG 1 An example avatar of a participant's persecutory voice, from AVATAR therapy.

Results from a recent proof-of-concept study of AVATAR therapy are promising (Reference Leff, Williams and HuckvaleLeff 2013) and a larger RCT of AVATAR therapy is currently underway (Reference Craig, Rus-Calafell and WardCraig 2015). Professor Tom Craig, who leads the AVATAR trial, has commented that VR gives ‘one sort of handle on psychotic experience that we've never had before’ and may enhance intervention potency (T. Craig, interview with P.O'H., 2015). Since AVATAR therapy requires significant therapist expertise and time, and uses expensive equipment, future research will need to demonstrate positive effects on real-world outcomes in definitive trials, and weigh up effectiveness against the cost of delivery.

Building an evidence base

First, clinical effectiveness and cost-effectiveness have hardly been addressed by existing studies. Since we know so little about the digital lives of people with psychosis, and in light of evidence that characteristics such as cognitive deficit and disorganised thinking can make navigating mainstream user interfaces difficult (Reference Rotundi, Anderson and HaasRotundi 2010), research to date has focused on establishing feasibility and usability of interventions. There is now substantial evidence from small-scale feasibility studies that people with psychosis are interested in and able to use a diverse array of digital technology interventions designed to accommodate their particular needs (Reference Naslund, Marsch and McHugoNaslund 2015). However, with technology advancing at a rate that far outpaces the time lines of RCTs, there is a risk that the technology underpinning these interventions will become outdated before their efficacy has been investigated. For example, with smartphone manufacturers releasing upwards of two new models a year, smartphone functionality will have advanced six times during the lifespan of a definitive RCT. People's expectations are likely to be shaped by their experience of rapidly advancing technology in other parts of their lives – as evidenced by participants’ feedback for Bias Buster – and this is likely to affect the acceptability of digital interventions.

Developers and researchers should seek to incorporate emerging technologies into novel interventions, to progress as quickly as possible to trialling them in adequately powered RCTs, and to rapidly disseminate findings from development and evaluation stages in order to keep up with technological developments.

Engaging the patient

Second, early indicators of poor engagement are emerging from studies of low-intensity e-interventions for psychosis (e.g. Reference Gottlieb, Harper Romeo and PennGottlieb 2013). There is some evidence to suggest that interactive technology, including gaming techniques (Reference Chan, Ngai and LeungChan 2010) and VR (Reference Park, Ku and ChoiPark 2011), may enhance participants’ engagement and motivation. However, substantial evidence suggests that supported self-help interventions – including e-interventions – for common mental health problems are more effective (Reference Musiat and TarrierMusiat 2014) and associated with higher rates of completion (Reference Richards and RichardsonRichards 2012) than unsupported interventions, and this is likely to be the case for emerging e-interventions for psychosis. It is less clear how the type, amount or mode of delivery (e.g. face-to-face, telephone or online) of support or who provides it (e.g. mental health professional or support worker) affect outcomes (Reference Musiat and TarrierMusiat 2014), and this will need attention in future research into e-interventions for psychosis. The existing and emerging technologies discussed here – including sensor technologies, gaming and VR – could be blended in future interventions with technology-enabled human support (e.g. via SMS, email or moderated forums) to develop novel ICT interventions with tailored, timely and engaging content and low-intensity therapeutic contact.

Engaging the clinician

Third, digitised methods must gain acceptance among clinicians if they are to be implemented successfully. Findings from the ITAREPS trial suggested that many treating psychiatrists failed to adhere to the treatment protocol because they lacked confidence in a system of assessment based on rating scales and IT. Qualitative data from the DIALOG+ trial are not yet available, but findings of poor clinician adherence to an intervention that requires minimal training and no service reorganisation (Reference Priebe, Kelley and OmerPriebe 2015) highlight the importance of understanding and addressing likely implementation challenges for more complex technology-based treatments.

Clinician involvement in the development and evaluation of digital tools, and adequate support to promote the uptake of novel interventions, will be essential for the successful incorporation of new technologies in clinical practice.

Barriers to access

Finally, e-interventions could exacerbate inequalities in service provision. Technology can only extend the reach of services if patients can access and engage with it. Access to technology does appear to be reduced in people with psychosis compared with the general population, and especially among people who are older, of a Black or ethnic minority background, have lower income and experience greater functional impairment (Reference Ennis and WykesEnnis 2012; Reference Firth and TorousFirth 2015). Wide roll-out of e-interventions without additional support for these groups would risk further marginalisation. Furthermore, neither access nor interest is the same as engagement, and we need a better understanding of how income, educational level, ethnicity and age affect the digital lives of people with psychosis and their ability to use e-interventions effectively.