Smartphones for Smarter Care? Self-Management in Schizophrenia
Publication: American Journal of Psychiatry
The patient with schizophrenia described in this article sought out smartphone applications for which of the following reasons?
A.
Social networking with other patients.
B.
Antipsychotic medication information.
C.
Supplemental counseling for schizophrenia.
D.
Support in weight-loss management.
“Mr. A” is a 30-year-old orthodox Christian single man, originally from Eritrea, who has been diagnosed with schizophrenia. He lived in a refugee camp for 9 months before arriving in the United States. Five months after his arrival, Mr. A started to feel “irritable, aggressive, disoriented, and confused.” Shortly thereafter, he experienced his first psychotic break. As a consequence, he could not retain his job, lost interest in school, and was asked to leave his relative’s house: in the Eritrean community, mental health problems are poorly understood and not well received. He was soon hospitalized for psychosis, the first of many experiences with the U.S. mental health care system. After his discharge, he discontinued his medication and psychotherapy sessions because he denied having a mental illness.
Beginning in his mid-20s, Mr. A had irritable mood, lack of sleep, constant interpersonal difficulties (not being able to understand the content and context of his social interactions), and psychotic symptoms (e.g., he was convinced that strangers on the street were talking disparagingly about him; voices persuaded him to travel from Boston to New York City, thinking that his symptoms would disappear if he moved to a different city). In his first year in the United States, Mr. A was hospitalized three times, precipitated by paranoia, fear of being attacked, and elevated mood. Mr. A attributed his relapse to his cultural and religious background: “Being mentally ill is taboo, it means that you are weak.” Further contributing to his relapse were medication nonadherence and side effects, including weight gain and obesity, which are also not accepted in his culture. A total of five medication attempts and 3 years of psychotherapy were required to stabilize him. Lack of social support, unstable housing, unstructured daily life, and intermittent psychotic symptoms led to homelessness until Mr. A was picked up by a local shelter in Boston. Four years ago, after another hospitalization, he was referred to a state outpatient clinic for ongoing psychiatric treatment, where he is currently treated.
Mr. A’s therapist helped him overcome his paranoia and connected him to resources, such as housing, food assistance, and other medical services. While attending therapy, he looked into additional services to supplement his quarterly appointments with his psychiatrist and his twice monthly psychotherapy sessions. Without discussion or consultation with his treatment team, he decided to explore mental health–related smartphone apps to see what they could offer him: “I was being creative in solving my problems, and I needed extra help with my counseling, so that’s why I chose to start with the apps store,” he explained. His app store search included keywords such as “counseling for schizophrenia” and “DBT [dialectical behavior therapy] for schizophrenia.” As he learned more about his symptoms, he used more specific search terms: emotional intelligence, facial reading, cognitive abilities (e.g., speed reading), and memory exercises. He downloaded several mobile apps based on their topics and online ratings.
Treatment as Usual
Before he started using smartphone apps, Mr. A was, for the most part, psychiatrically and emotionally stable. The emphasis in therapy was on working on cognitive-behavioral skills to manage symptoms; as a result, Mr. A became aware of his negative and positive symptoms as well as the importance of taking his medications. However, he reported that he could not move forward with his life because he needed to improve in areas that were not part of his psychiatric treatment; getting and maintaining a job, socializing with the community, and acting/reacting in ambiguous social situations were all areas in which Mr. A struggled despite therapy: “I need help to practice my social and emotional skills in scenarios related to my life circumstances,” he said. “I need someone to give me feedback about what I do in those cases.” Additionally, he felt that his therapy could benefit from more frequent sessions and clearer explanations about his condition and symptoms.
Smartphone Intervention
Mr. A turned to smartphone apps to help fill these gaps in his treatment. He most frequently utilized “DBT 911,” “Facial and Emotion Recognition,” and “Virtual Hope Box.” These apps provided education about his illness and helped him monitor his symptoms. He experimented briefly with 20 other apps, the names of which he does not recall. He also learned and practiced cognitive-behavioral skills, breathing relaxation techniques, social cue identification, and emotion regulation and recognition. The Facial and Emotion Recognition app, for instance, allowed him to practice reading facial expressions in people of different ages, ethnicities, races, and genders in a way that face-to-face therapy could not. DBT 911 helped Mr. A understand and identify his emotions, practice mindfulness, manage relationships, and develop distress tolerance skills in scenarios relevant to his recovery plan. Virtual Hope Box helped him customize, organize, and plan several coping strategies into a recovery agenda that he could use during the week or for specific situations. His customized intervention included scheduling positive thoughts, listening to music or watching videos as a distraction strategy, practicing guided imagery, and using controlled breathing.
Intervention by the therapist (L.R.S.) focused on detection of early signs of distress. This motivated Mr. A to search for apps that could complement and expand his sessions outside the clinical setting. Over time, Mr. A (in consultation with his therapist) created his own app-based treatment plan to supplement the one that was offered in the clinic. Mr. A’s main therapeutic goals were threefold: to manage paranoid thoughts, to cope with social and cultural stressors, and to improve cognition.
Mr. A began to understand his symptoms, to gain more insight and self-reflection, and to improve his adherence to clinic visits and medication. He became a proponent of his own treatment by suggesting treatment options in the same way a therapist would, and he empowered his experience as a patient by testing multiple technologies on himself and reporting his findings. The clinician provided a safe environment, fine-tuning of the intervention, and clinical expertise, listening, and the validation that a computer cannot offer. However, it was only with the help of apps that Mr. A was able to understand, learn, and practice cognitive-behavioral skills both to prevent relapses and to increase his functionality in the community.
Discussion
Mr. A’s case was presented as part of grand rounds at the Massachusetts Mental Health Center, and the resulting discussion is summarized below. The patient consented to publication of this report, but the case presentation above is nevertheless anonymized.
The rapid rise of smartphone technology and increased rates of smartphone ownership among patients with serious mental illness (1) is narrowing the digital divide between those in this population who own and use digital technologies and those who do not (2, 3). Research surveys suggest that some individuals with schizophrenia own multiple connected devices, and a small subset may spend more than 10 hours per day using their smartphones (4). Preliminary research has shown the feasibility of using smartphones and apps to help manage psychotic symptoms (5, 6), monitor medications (7), predict relapse (8), and improve quality of life (9). However, the literature on the use of mobile technologies for schizophrenia remains sparse, and while early studies are encouraging, reproducibility and efficacy remain largely unknown.
Advantages of Apps
Among the perceived advantages of apps are affordability, accessibility, minimal commitment, engagement, and lack of stigma—several of which drew Mr. A to explore apps.
Affordability.
The mental health apps that Mr. A found were inexpensive or free (ranging in price from $0 to $9.99). This contrasts with the costs of traditional therapy, which is often out of reach for patients like Mr. A. While the quality and effectiveness of most apps remain in question (10), the affordability was appealing to Mr. A.
Accessibility.
Mr. A found apps to be accessible and practical. More than two-thirds of U.S. adults connect to the Internet via smartphones (10); downloading an app is practical for most. “It was great to practice my skills on my way home [on the bus] in addition to clinic visits,” explained Mr. A. In an increasingly on-demand culture, the ability to access mental health apps is appealing to patients like Mr. A.
Minimal commitment.
Mr. A liked the fact that he could install and uninstall apps within seconds, without having to explain his reasoning, and with no economic or legal penalties for doing so. This freedom allowed him to try multiple apps in a given category before committing to one for a longer trial. While the lack of “therapeutic alliance” or commitment are concerning, the autonomy conferred by apps is itself an appealing factor.
Engaging.
Mr. A reported that using the apps was fun and enjoyable. Some apps are presented in game-like formats (e.g., the cognition app Lumosity), in which users are challenged to provide the correct answers in order to win points or open new levels. While many mental health apps suffer from poor engagement (11), with many users never accessing an app more than once, Mr. A’s case demonstrates that with the right match, engagement can be high and drive app use.
Nonstigmatizing.
Mr. A reported feeling safe and comfortable accessing mental health services through his smartphone, without fear of being stigmatized by others as a mental health patient. While early data suggest that social media and online resources accessed by individuals with schizophrenia are not completely stigma free (12), the anonymity afforded by apps is a valued feature to those like Mr. A.
Challenges of Apps
Apps have several weaknesses that patients, and often clinicians, are unaware of. These include privacy and safety, evidence and efficacy, usability, and interoperability, as suggested by the APA’s app evaluation framework (13).
Privacy and safety.
Safeguards such as encryption, secure storage, and transfer of data are often lacking in apps; the majority of commercially available health apps fall outside the scope of privacy laws (14). Mr. A was unaware that some apps may market mental health data he supplied to the apps (15), and he acknowledged that he never even considered looking at the apps’ privacy policies. In patients with cognitive impairments, the complexity of app privacy policies and the lack of standardized safeguards is concerning. Additionally, Mr. A noted that several apps did not understand the context of his questions and sometimes provided what he called “odd responses.” Mental health apps often provide incorrect information (16), and current mobile health technologies are not designed to respond to emergencies, such as suicidality (17).
Evidence and efficacy.
Usability.
Without high levels of patient engagement, apps cannot be useful. While Mr. A eventually found several apps that were engaging for him, he also quickly abandoned several others. App engagement declines exponentially in general (11). Most health apps are not designed for easy use by persons with serious mental illness. Mr. A reported that “sometimes the terminologies used in the app were not easy to understand.”
Interoperability.
Few apps can easily share data with clinicians or integrate information into the electronic medical record. Mr. A had been using apps for several months before he even informed his clinical team. The fragmenting of care through apps is a concern raised by the U.S. Department of Health and Human Services, and it underscores the need for apps to be used as part of the treatment plan and not around or in lieu of it (19). It is worth routinely asking patients if they are using apps, just as one may ask about supplement use.
Summary and Conclusions
This case report highlights the role apps have in psychiatric treatment, both within and outside a clinical setting. Patients are increasingly becoming more informed and proactive about their mental health care and many are seeking technology-oriented and self-directed treatment options. In the next decade, it will be up to the clinical community to see that such technology is implemented as part of a reliable mental health standard of care. Emerging challenges include inappropriate app content, scarcity of technical expertise, lack of regulation and standardization, privacy issues, and variable navigability. Increasing technological literacy will be important for frontline clinicians who wish to help patients make informed decisions about the risks and benefits of digital psychiatry tools like smartphone apps. More research is needed to establish the efficacy of apps in mental health treatment.
C. Supplemental counseling for schizophrenia
Want more? A CME course is available in the APA Learning Center at education.psychiatry.org
Acknowledgments
The authors gratefully acknowledge support from the Myrtlewood Foundation for work related to digital mental health. Dr. Torous is supported by a training grant from the National Library of Medicine (T15LM007092-25).
References
1.
Torous J, Chan SR, Yee-Marie Tan S, et al: Patient smartphone ownership and interest in mobile apps to monitor symptoms of mental health conditions: a survey in four geographically distinct psychiatric clinics. JMIR Ment Health 2014; 1:e5
2.
Firth J, Cotter J, Torous J, et al: Mobile phone ownership and endorsement of “mHealth” among people with psychosis: a meta-analysis of cross-sectional studies. Schizophr Bull 2016; 42:448–455
3.
Robotham D, Satkunanathan S, Doughty L, et al: Do we still have a digital divide in mental health? A five-year survey follow-up. J Med Internet Res 2016; 18(11):e309
4.
Gay K, Torous J, Joseph A, et al: Digital technology use among individuals with schizophrenia: results of an online survey. JMIR Ment Health 2016; 3(2):e15
5.
Firth J, Torous J: Smartphone apps for schizophrenia: a systematic review. JMIR mHealth uHealth 2015; 3(4):e102
6.
Ben-Zeev D, Brenner CJ, Begale M, et al: Feasibility, acceptability, and preliminary efficacy of a smartphone intervention for schizophrenia. Schizophr Bull 2014; 40:1244–1253
7.
Kannisto KA, Adams CE, Koivunen M, et al: Feedback on SMS reminders to encourage adherence among patients taking antipsychotic medication: a cross-sectional survey nested within a randomised trial. BMJ Open 2015; 5:e008574
8.
Wang R, Aung MS, Abdullah S, et al: CrossCheck: Toward passive sensing and detection of mental health changes in people with schizophrenia. Proceedings of the 2016 ACM International Joint Conference on Pervasive and Ubiquitous Computing, Sept 12, 2016, pp 886–897 (http://pac.cs.cornell.edu/pubs/Ubicomp2016_Crosscheck.pdf)
9.
Schlosser D, Campellone T, Kim D, et al: Feasibility of PRIME: a cognitive neuroscience-informed mobile app intervention to enhance motivated behavior and improve quality of life in recent onset schizophrenia. JMIR Res Protoc 2016; 5:e77
10.
Perrin A, Duggan M: Americans’ Internet Access: 2000–2015. Washington, DC, Pew Research Center, June 26, 2015. http://www.pewinternet.org/2015/06/26/americans-internet-access-2000-2015/
11.
Frisbee KL: Variations in the use of mHealth tools: the VA Mobile Health Study. JMIR Mhealth Uhealth 2016; 4:e89
12.
American Psychiatric Association: App Evaluation Model. https://psychiatry.org/psychiatrists/practice/mental-health-apps/app-evaluation-model
13.
Torous J, Keshavan M: The role of social media in schizophrenia: evaluating risks, benefits, and potential. Curr Opin Psychiatry 2016; 29:190–195
14.
Examining Oversight of the Privacy and Security of Health Data Collected by Entities Not Regulated by HIPAA. Washington, DC, US Department of Health and Human Services, July 19, 2016. https://www.healthit.gov/buzz-blog/privacy-and-security-of-ehrs/examining-oversight-privacy-security-health-data-collected-entities-not-regulated-hipaa/
15.
Glenn T, Monteith S: Privacy in the digital world: medical and health data outside of HIPAA protections. Curr Psychiatry Rep 2014; 16:494
16.
Nicholas J, Larsen ME, Proudfoot J, et al: Mobile apps for bipolar disorder: a systematic review of features and content quality. J Med Internet Res 2015; 17:e198
17.
Larsen ME, Nicholas J, Christensen H: A systematic assessment of smartphone tools for suicide prevention. PLoS One 2016; 11:e0152285
18.
Gilbody S, Littlewood E, Hewitt C, et al: Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ 2015; 351:h5627
19.
Bobinet K, Petito J: Designing the Consumer-Centered Telehealth and eVisit Experience: Considerations for the Future of Consumer Healthcare (White Paper prepared for the Office of National Coordinator for Health Information Technology, US Department of Health and Human Services). Washington, DC, US Department of Health and Human Services, 2015. https://www.healthit.gov/sites/default/files/DesigningConsumerCenteredTelehealtheVisit-ONC-WHITEPAPER-2015V2edits.pdf
Information & Authors
Information
Published In
History
Received: 1 September 2016
Revision received: 9 January 2017
Accepted: 23 January 2017
Published online: 1 August 2017
Published in print: August 01, 2017
Keywords
Authors
Funding Information
The authors report no financial relationships with commercial interests.
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).