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

Lead Research Organisation: University of Manchester
Department Name: School of Health Sciences

Abstract

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.

Technical Summary

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.

Planned Impact

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 antreatment 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.
 
Title Actissist Logo 
Description Actissist Logo was created and IP assigned to University of Manchester 
Type Of Art Image 
Year Produced 2015 
Impact Not known. 
 
Title Audio recordings 
Description 4 relaxation audio-recordings by UoM staff (SB x2 and RM x2) 4 mindfulness audio recordings by UoM staff (SB x2 and RM x2) 
Type Of Art Film/Video/Animation 
Year Produced 2015 
Impact Nil 
 
Title Patient recovery videos 
Description 1 video created (IP assigned to University of Manchester by actor in one film external toUniversity) depicting an actor's patient recovery journey. Facilitated and co-ordianted by ROhan Morris, RA. 
Type Of Art Film/Video/Animation 
Year Produced 2015 
Impact Nil 
 
Description Biomedical Catalyst
Amount £1,600,000 (GBP)
Funding ID MR/P026664/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 10/2017 
End 09/2020
 
Description EMPOWER 
Organisation University of Glasgow
Department School of Psychology
Country United Kingdom 
Sector Academic/University 
PI Contribution Collaborated on a successfully funded NIHR / NHMRC research grant led by Prof Andrew Gumley at Glasgow University. The Actissist technology will be used as part of the intervention developed in this new trial.
Collaborator Contribution Provided intellectual input into designing a new digitally-supported intervention for schizophrenia targeting relapse. Ideas in Actissist will be drawn on on developing this new digitally supported intervention package.
Impact NA
Start Year 2016
 
Description UK Health Data Analytics Network 
Organisation UK Data Service
Country United Kingdom 
Sector Academic/University 
PI Contribution Attendance and participation to discussion groups/developing key mental health strategy for health data analytics framework
Collaborator Contribution Suggestions regarding ways to analyse real-time data
Impact Multi-disciplinary collaboration. Outputs not currently generated. Sharing of ideas.
Start Year 2015
 
Description  
IP Reference  
Protection Copyrighted (e.g. software)
Year Protection Granted
Licensed No
Impact Software code, clinical content and know-how developed to create a software app. Back ground IP taken from ClinTouch software, formerly owned by University of Manchester but now assigned to a start-up company spun out of the University of Manchester, Affigo CiC.
 
Description 8th World Congress of Behavioural and Cognitive Therapies 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Title: Active Assistance for Psychological Therapy (Actissist): A cognitive behavioural therapy informed smartphone intervention for early psychosis (Invited).
Symposium 1 Title: Developing digital interventions for people recovering from psychosis (Convenor: Dr Neil Thomas).
Presented at the 8th World Congress of Behavioural and Cognitive Therapies, June, 2016. Melbourne, Australia.
Year(s) Of Engagement Activity 2016
 
Description 8th World Congress of Behavioural and Cognitive Therapies, June, 2016. Melbourne, Australia. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Open paper presented at the 8th World Congress of Behavioural and Cognitive Therapies, June, 2016. Melbourne, Australi: Title: What Do Service Users Want for a Smartphone App for Psychosis?
Year(s) Of Engagement Activity 2016
 
Description Beckfest conference - Invited talk 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Invited talk to CBT experts internationally - presented trial results and design for Actissist
Year(s) Of Engagement Activity 2014,2016
 
Description ISRII - Conference Presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Talk given at an international conference in a symposium titled: Digital therapies for serious mental health problems which I also chaired. Approx 100 people attended the talk and there was important discussion around the use and implementation of DHIs in serious mental health conditions.
Year(s) Of Engagement Activity 2017
 
Description ISRII - Conference Presentation 2 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Approx 100 people attended the talk I gave on the outcomes of the trial. The talk was part of a larger symposium titled: Integration and implementation of digital tools into secondary care mental health services which i chaired.
Year(s) Of Engagement Activity 2017
 
Description Informatics for Health Conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Industry/Business
Results and Impact Present the Actissist trial at an Informatics conference which extended the reach of digital health work in mental health to more technologically-oriented audiences rather than mental health audiences. Over 100 people were in attendance and there were anecdotal reported changes in attitudes to technology use in mental health following presentation of this paper.
Year(s) Of Engagement Activity 2007,2017
 
Description Interview - MRC_Mental Health Strategy launch 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Interview with MRC alongside launch of new Mental Health Strategy
Year(s) Of Engagement Activity 2017
 
Description MindTech Launch Talk 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach National
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Presentation at the MindTech Launch Event, Royal College of Physicians, London. Actissist talk given to over 100 physicians, clinicians and academics. Presentation available on the internet and viewed by many.

Sharing of information regarding how technology can be used to deliver treatment to people with serious mental health problems. Change in views reported about the use of technology in serious mental illness.
Year(s) Of Engagement Activity 2013
 
Description Mobile Health Technology Conference Talk 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Conference day entitled 'Mobile Health Technology Conference' where around 100 researchers across various disciplines came together to share research projects and hear about research taking place across the UK.

Change in views on capability of technology to play a role in delivering healthcare for people with serious mental health problems.
Year(s) Of Engagement Activity 2013
 
Description Psychosis Interest Group Talk 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Presentation given to the Psychosis Interest Group, University of Manchester. Academics, clinicians and patients meet to hear about research taking place at the University in relation to psychosis.

Change in attitudes among clinicians and some academics regarding the importance of technology in mental health service delivery.
Year(s) Of Engagement Activity 2014
 
Description The University of Manchester Experience Sample Methodology group Seminar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact Presentation on Actissist at our local Experience Sample Methodology group Seminar - discussion focused on new methodologies for analysing digital intervention trials.
Year(s) Of Engagement Activity 2016
 
Description University workshop - mHealth & eHealth Innovation Review Meeting 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Other audiences
Results and Impact Workshop at University of Manchester on mHealth & eHealth Innovation - Review Meeting
Year(s) Of Engagement Activity 2016
 
Description Visit to Massachusetts Institute of Technology, Boston 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact I presented my research to a group of academics at MIT, Boston (approx. 20 people) and met individually with researchers to discuss possible collaborations regarding my research (approx. 5 people individually). I also met opportunistically with academics carrying out related research (approx. 15 academics).

Email contact and Skype meetings with 2 researchers from Boston University.
Year(s) Of Engagement Activity 2014
 
Description mHealth (UMIP) Talk 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact University of Manchester Intellectual Property (UMIP) Department undertook a review of the activity and related Intellectual Property in mobile and electronic health (mhealth and ehealth) across the University. A member of staff spoke to a sample of the academics active in that field. Having interviewed 30+ academic and support staff across the University most expressed an interest in hearing about the results. This event is an opportunity for staff to present their findings to the University mHealth community giving an overview of the University's activity and the grant opportunities, potential markets and potential sources of funding. I gave a brief presentation on my current research as an example of the work being undertaken. This target audience was academic researchers, research support managers, Industry engagement.

Individual meetings in place with academics from cross-disciplines.
Year(s) Of Engagement Activity 2014