Active Assistance for Psychological Therapy (Actissist): Software to improve access and adherence to CBT targeting key relapse indicators in psychosis

Serious mental health problems such as schizophrenia affect 24 million people worldwide. Schizophrenia is the most serious form of psychosis. Psychosis is a general term that describes a change in people's behaviour, thinking and perception. Psychosis affects people's ability to socialise, work and carry out the tasks of daily life, and usually begins in early adulthood. First episode psychosis is the first time someone experiences these changes. The period following a first episode of psychosis is critical in the long-term course of illness development. This is because the majority of people relapse, or experience more than one episode of psychosis. This makes the early phase of psychosis an important time to deliver treatment, because the longer the delay in treating psychosis, the worse the illness becomes. There is evidence that a talking therapy ('cognitive behaviour therapy' or CBT), as well as medication, can help reduce symptoms of psychosis further. Unfortunately, only 1 in 10 of those who could benefit from CBT have access to this treatment. This is for a variety of reasons, including a shortage of trained staff and pressure on health service resources. Even when people are offered CBT, they often don't receive it until late in their illness. In recent years, smartphones have become very popular. Smartphones are able to run advanced software applications, called 'apps'. Some healthcare treatments have already been successfully delivered using smartphone 'apps'.

This study aims to develop and test the possible benefits of a CBT 'app' in the early stages of psychosis. Our goal is to make helpful treatments such as CBT more accessible. By doing this, we hope to reduce the number of psychotic episodes people experience, or at least keep these to a minimum. This is a proof of concept study. This means that we will provide 24 people with a CBT smartphone 'app', and 12 people with a smartphone 'app' designed to simply monitor psychosis and other symptoms. Which treatment people get will be randomly determined so that the treatments can be compared in similar groups of people. We expect the CBT 'app' will bring improvements in quality of life, social interactions and other important factors. We hope to gain a greater understanding of the possible benefits to delivering helpful treatments in the form of a mobile phone 'app'. We are also interested to see whether people like using the CBT 'app'.

Our CBT 'app' will make helpful therapies more accessible for people with lived experience of psychosis. We will do this by translating CBT into a user-friendly 'app' that will be delivered through a familiar device (mobile phone) that people, especially young people, enjoy using. By doing this, we hope that we can help people notice if they are becoming unwell at an earlier point than if they relied on attending a mental health service. We hope that this will improve people's daily lives and keep them out of hospital. This study will provide patients, services and commissioners with information about different ways people can access healthcare. We would like to make helpful therapies widely available so more people feel empowered to make informed choices about their health care. Our 'app' has the potential to transform community care for people with serious mental illness with personalised self-management of symptoms and therapy.

Schizophrenia is a serious mental illness affecting 2% of the population. The majority of first episode of psychosis (FEP) patients reach remission within 12-months of treatment. However, the early course of psychosis is characterized by repeated relapse; 80% of FEP patients will relapse within 5-years of their initial episode, adversely impacting on their psychosocial development. The early phase following FEP is a critical period. Risk factors for relapse in FEP are non-adherence with medication, substance misuse, carers' critical comments and social isolation. NICE recommends cognitive behavioural therapy (CBT) in the treatment of schizophrenia, and CBT has been successfully applied in the treatment of FEP. However, a shortage of trained clinicians and resource pressures mean that of people with psychosis who could benefit, only 10% have access to CBT. Even those who are offered CBT often experience long delays before receiving treatment, resulting in relapse indicators being missed. Accordingly, there is an urgent need for innovative, cost-effective solutions that improve access to CBT and deliver treatment in a timely manner. Active Assistance for Psychological Therapy (Actissist) will be a smartphone software application that will provide such a solution by delivering an interactive, personalised CBT intervention targeting the key psychosis relapse indicators in FEP. By leveraging the capabilities of smartphones, Actissist will allow patients to create and manage a repository of personally meaningful, multi-media CBT strategies as part of their everyday lives. We envisage Actissist as a reusable platform capable of delivering interventions for many disorders. This research builds on ClinTouch, an MRC funded mobile phone symptom-monitoring system for schizophrenia, by extending the concept to provide psychological intervention. The proposed 26-months project is designed to provide proof of concept, with results informing a future phase III effectiveness trial.

The Schizophrenia Commission (2012) found that early intervention in psychosis has the potential to save the NHS £119m, with £125m saving for the Exchequer over three years. Currently, the cost of treating relapsing psychosis is 4-times that of stable psychosis. Despite the rise of community care, 70% of the costs of SMI are on unplanned inpatient care for relapse. Even if hospital admissions are reduced by 10%, cost savings to the NHS will be significant.

As the early course of psychosis is sharply predictive of longer-term course of illness, timely, effective and accessible interventions have the potential to prevent the development of more serious forms of psychosis, such as schizophrenia. The early phase following the onset of first episode of psychosis (FEP) is a critical period, influencing the long-term course of illness. Following a FEP, 80% of people will relapse within 5-years. Schizophrenia is the most serious form of psychosis. Psychological therapy, specifically CBT, is strongly recommend in the treatment of psychosis. Unfortunately, access to CBT is significantly limited. The proposed programme of research has the potential to benefit people with serious mental illness accessing NHS mental health services by:
- increasing the provision of, and access to, CBT without increasing qualified clinicians by delivering a personalised intervention at an earlier point than is otherwise possible with conventional services;
- ensuring psychosis relapse indicators are identified and treated in a timely manner;
- enhancing the quality of the patient experience by empowering patients and enabling self-management of symptoms and therapy;
- enhancing patient's quality of life as a result of fewer relapses and preventing avoidable hospital admissions.

NHS clinicians working in Mental Health Trusts across the UK will also benefit from the proposed programme of research. If successful, clinicians could use Actissist as an adjunct to routine clinical assessments and treatment delivery. For example, representations of momentary data will allow for ecologically-valid psychological formulations to be developed in clinician-led therapy.

Actissist will be a smartphone software application that will deliver an interactive, personalised CBT intervention targeting the key psychosis relapse indicators in FEP. We envisage Actissist as a reusable platform capable of delivering interventions for many disorders. If Actissist proves to be feasible, acceptable and efficacious in FEP, all patients who benefit from CBT could potentially benefit from CBT delivered via smartphone technology.