Active Assistance for Psychological Therapy 2.0 (Actissist 2.0): Digital Intervention for Co-producing care in psychosis.

Severe mental health problems (SMI) such as schizophrenia affect 24 million people worldwide. Schizophrenia is a severe form of psychosis - a general term that describes a change in people's behaviour, thinking and feelings. Psychosis affects people's ability to socialise, work and carry out the tasks of daily life. It usually begins in early adulthood. First episode psychosis is the first time someone experiences these changes. Most people with psychosis have more than one episode of psychosis, so people are at risk of long-term problems. The time after a first episode of psychosis is critical for a person's long-term recovery. This makes the early phase of psychosis an important time for treatment. The longer the delay in treating psychosis, the worse the illness becomes. The delivery of efficient and timely talking treatments for psychosis is a serious challenge in the current NHS climate. Traditional ways of offering therapy through face-to-face appointments can effect how efficiently treatment can be offered. We need increased availability and new, timely ways of delivering therapy when it is needed. Smartphones are now affordable and popular and are one way we can successfully deliver treatment safely and at point-of-need.

Grounded in psychological theory and principles, we have developed a Smartphone app called Actissist that people can access anywhere, at the time they need it. In our previous research, we showed that people with early psychosis completed the app swiftly in their daily life over 12 weeks. We also showed that people liked using the app and that it was safe to use. The study we propose for this application is the next step along the research pathway. We aim to improve and test the benefits of our digital intervention by giving it to 75 early psychosis patients. We will compare outcomes with 75 people who use a different app (called ClinTouch), which just monitors psychosis and mood symptoms but does not provide self-managed therapy. Which app people get will be determined by chance so that the treatment can be compared in similar groups of people. Based on our previous work, we hope that Actissist will improve symptoms and other important areas of people's lives. We hope to gain a better understanding of how we can use digital technology to help provide day-to-day care. Finally, we hope that the Actissist app will empower people to self-manage their symptoms and therapy.

Our overarching goal is to transform community care for severe mental health conditions and to give individuals more choice about how they receive healthcare and interact with services. By doing this, we hope to reduce the number of episodes of psychosis people have or at least keep these to a minimum. We will do this by translating psychological ideas and strategies into a user-friendly digital intervention that will be delivered through a Smartphone, which most people own and 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 receive healthcare. We would like to make helpful treatments more accessible and provide choice about how therapy is delivered. Our vision is to give people a greater sense of control over their mental health and wellbeing, support the speed and quality of recovery over and above drug treatments while sustaining functional outcomes, and to support self-management.

Severe mental illness (SMI) such as schizophrenia affects 24 million people worldwide, with societal costs estimated at nearly £12bn in England. Onset typically occurs in early adulthood and up to 80% relapse within 5-years, resulting in unscheduled acute care and adverse effects on psychosocial development. The main treatment for psychosis is medication and psychosocial interventions. Currently, the delivery of psychosocial interventions for psychosis by scheduled appointment can result in psychosis relapse indicators either being missed or treated too late. There is a need for innovative, timely, efficient and cost-effective solutions to improve the speed and quality of recovery in psychosis, over and above conventional drug and psychosocial treatments. The NHS has a clear digital agenda for addressing mental health challenges, aiming to fully harness the information technology revolution, and self-management in long-term conditions is a cornerstone of NHS policy. Smartphones offer an unprecedented opportunity to drive improvements in treatment quality, efficiency, cost, access and facilitate self-management. Supported by MRC DPFS funding (MR/L005301/1), we have developed a user-informed, personalised, smartphone app, Actissist, that delivers a theory-driven psychological intervention that is unconstrained by traditional service settings. We have shown that patients complete the intervention swiftly in the course of daily life over 12-weeks and that this technology is feasible, safe and acceptable. The primary aim of the current proposal, Actissist 2.0, is to refine the software and conduct an efficacy study in psychosis. Actissist 2.0 supports active shared decision-making about treatment. Results will inform a future Phase III effectiveness trial and shape where digital interventions fit on the healthcare pathway, including opportunities for commercial partnerships.

This project directly impacts vulnerable individuals with psychosis, their families/wider community, the scientific community, and addresses national government policies.

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 severe mental health problems (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, accessible and affordable interventions have the potential to prevent the development of more serious forms of psychosis, such as schizophrenia.

Impacting patients: The proposed programme of research has the potential to benefit help-seeking SMI patients by scaling up the provision of, and timely access to, self-managed therapy by delivering treatment at the point-of-need at an earlier point than is otherwise possible within conventional service settings. In this trial, 150 patients will have access to the digital intervention we have developed and seek to refine. We will aim to recruit participants as widely as possible to give as many individuals as possible the opportunity to participate in the study. Currently, there are no other theory-driven apps for psychosis in the local area. Conducting this project and gathering scientific data will help optimise implementation and increase the likelihood that the intervention will be scaled up nationally. We will set up an expert reference group and conduct network meetings to strengthen community networks.

NHS clinicians: Clinicians and services will also benefit. Clinicians will be able to 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. The app will also facilitate shared decision-making, a priority identified in the Schizophrenia Commission Report (2012).

Impacting participating services for adoption: Adoption of the intervention will be highly dependent on staff, service and commissioner engagement. We will liaise closely with local managers and commissioners throughout the project to discuss potential implementation strategies. Data gathered from our proof-of-concept trial and in further qualitative work will help us identify barriers/facilitators to implementation, including how the intervention works in specific contexts (e.g. service setting).

Impacting policy: Self-management is a cornerstone of NHS policy. Our proposal addresses established NHS England priorities in the area of SMI treatment policy. Findings will inform: i) the "Five Year Forward View", which identified a clear direction for addressing mental health challenges such as delivering efficient and good quality SMI care; ii) NICE guidelines for schizophrenia and psychoses, in terms of how we can utilise and optimise self-management and treatment choice on the healthcare pathway; iii) Department of Health (2016) mandate for early intervention service access and waiting times for a NICE-approved treatment package; iv) NHS digital agenda - NHS England is committed to sustain implementation efforts using innovative technologies, providing affordable, available healthcare for SMI patients.

All SMI patients have the potential to benefit from timely, available and accessible self-management via our Smartphone technology platform. The path we establish will be reusable by subsequent developers of digital interventions and will therefore have a significant impact on the scientific and technology communities.