Moderated Online Social Therapy for Recovery From Early Psychosis

Psychotic disorders are among the most distressing and disabling of psychiatric conditions. Their onset, characteristically in late adolescence when young people face significant developmental challenges, poses a significant risk of lifelong disability and compromised mental and physical health. Recurrent psychotic episodes, poor physical health, long-term unemployment, social anxiety, substance abuse, chronic depression, and even suicide are causes for concern after first-episode psychosis.

Over the preceding 20 years, specialist early psychosis programs have evolved internationally in order to provide a more timely treatment and to support young people in achieving symptomatic remission and eventual full recovery. However, there are considerable challenges to achieving these aims. First, despite research showing that 90% of patients who receive treatment achieve good short-term symptomatic outcomes, a majority remain at risk of recurrence of acute symptoms. These relapses can lead to ongoing, chronic psychosis. Second, patients with a first episode of psychosis are at risk of experiencing secondary illnesses, including depression, anxiety, and compromised physical health as a result of rapid and pronounced weight gain and related metabolic disturbances. Third, although most young patients with first-episode psychosis participate over the short term in effective psychosocial and biological treatment programs, continuing with treatment and maintaining early gains is a major challenge for the field. For example, at the Early Psychosis Prevention and Intervention Centre, a specialist service for treating early psychosis, we developed an effective cognitive-behavioral therapy-based program for the prevention of relapse among first-episode patients who had reached remission of positive symptoms for a period of one month. The program showed significant benefits compared with specialist early psychosis treatment alone in terms of relapse rates over the first 12 months, but treatment effects were lost by the 18-month follow-up.

Members of our group have also developed and evaluated a program for the prevention of weight gain associated with first-episode psychosis, which had a similar early, but unsustained pattern of results. Taken together, these results highlight the need to maintain effective psychosocial interventions over the long term after the onset of first-episode psychosis. However, even though five years is considered optimal, specialist early psychosis programs typically have treatment resources to support only 18 months to two years of follow-up. So clearly, novel, cost-effective, and youth-friendly strategies are required to address these problems in order to optimize the recovery of young people after their first episode of psychosis.

One strategy our team has been working on is the utilization of information and communication technology (ICT), which has already frequently been applied to the treatment of depression, anxiety, and other mental health conditions. These Internet-based therapies have typically facilitated the interaction of a single user with an automated education program. Online discussion forums have also proliferated, but these generally lack evidence-based therapeutic content. Despite high rates of access to the Internet among young people, the application of online therapies to treat early psychosis has been extremely limited.

We have formulated a new model of providing online interventions for first-episode psychosis and built a Web-based intervention informed by the model. Called the moderated online social therapy model, our ICT model has been developed by a multidisciplinary team of clinical psychologists, a computer programmer, a health informatics expert, a Web designer, a writer, and a graphic designer. The site has been built and was pilot-tested in March in consultation with young people with diagnosed psychosis, clinicians, and young computer users. Full testing is planned for 2013.

The Web site integrates therapy modules (our “coach menu”) with a private moderated social networking function (our “cafe menu”). The modules begin with an interactive welcome segment. Subsequent interactive modules address psychoeducation, relapse prevention, stigma and social anxiety, early warning signs of relapse, depression, and identification and use of personal strengths. The cafe functions include a personal profile page (which can be kept anonymous if the user prefers), a network (similar to a “friends” function in social networking), a group problem-solving function (based on traditional social problem-solving therapy in which participants can draw on ideas from other users to generate solutions to everyday problems faced in recovery), and discussion threads linked to the modules. A “wall” function organizes discussion threads into relevant themes such as “what works for me,” where clients share successful approaches. A separate moderator interface enables daily guidance of discussions, risk monitoring, and tracking patterns of use. We suspect that this will be both an effective relapse prevention tool as well as a highly appealing and intuitive structure for young people to engage with each other and with expert moderators.