Skip to main content
Full access
Articles
Published Online: 16 October 2019

Perspectives on Mobile Health Versus Clinic-Based Group Interventions for People With Serious Mental Illnesses: A Qualitative Study

Abstract

Objective:

This study built on research comparing a mobile health intervention (FOCUS) and a clinic-based intervention (Wellness Recovery Action Planning [WRAP]) for self-management of serious mental illnesses. Qualitative interviews were conducted to provide additional insight into engagement and satisfaction and augment understanding of clinical outcomes.

Methods:

Individuals (N=31) with serious mental illness participating in a comparative effectiveness trial were interviewed. Interviewees were sampled purposively for a range of engagement with the interventions. Interviews inquired into experiences with the interventions and were 45–60 minutes long, audio recorded, and transcribed. Researchers developed qualitative codes based on the research aims, interview domains, and inductively derived categories, aggregating data by code and producing analytic memos to distill main findings.

Results:

Both FOCUS and WRAP participants described gaining new information about mental illness and new skills for managing symptoms. FOCUS participants emphasized the intervention’s accessibility, and WRAP participants highlighted the importance of community and shared experiences. FOCUS participants commenced treatment at higher rates, compared with WRAP participants, which may have been related to the strongly negative views of group interventions expressed by some WRAP participants. FOCUS was generally enthusiastically received. The comparable clinical outcomes of the interventions were reflected in narratives detailing the positive impact of the interventions.

Conclusions:

Interviews provided evidence that mobile health and clinic-based illness self-management interventions were well received and offered opportunities to learn new illness management skills. Findings support expanding the range of services and supports for persons with serious mental illness to include traditional and technology-based approaches.

HIGHLIGHTS

Integrating qualitative methods provides additional insight into main outcomes in mental health services research.
Both mHealth (FOCUS) and clinic-based (Wellness Recovery Action Plan) illness management interventions were well received by service users in a large community mental health center.
Participants were drawn to the accessibility of the mHealth approach and the opportunity to engage with a community of people with shared experiences in the clinic-based approach.
Most experiences with both interventions were positive, but qualitative interviews revealed potentially problematic aspects of both interventions, including the repetition of mHealth content and challenging group dynamics in the clinic-based intervention.
Individuals with serious mental illnesses experience functional impairment that interferes with activities such as work, independent living, and self-care (1). They often alternate between periods of elevated symptoms with significant impairment and periods of remission with improved functioning (2). Patients, caregivers, and providers have emphasized the need for interventions to help people manage their illnesses successfully and live meaningful lives (3, 4). Illness self-management interventions aim to help people develop coping skills to reduce the severity and distress of persistent symptoms (5).
Illness self-management interventions have been found to improve people’s knowledge about their illness and to help people develop coping skills that reduce the severity and distress associated with symptoms (5). One well-known evidence-based illness self-management program is Wellness Recovery Action Planning (WRAP) (6), which uses a peer-led, group-based approach. Sessions follow a sequenced curriculum, and discussion topics and examples draw from the personal experiences of the participants and cofacilitators in attendance. Group facilitators incorporate personal wellness tools into a written plan, which includes daily maintenance, identification of triggers and methods to avoid them, warning signs and response options, and a crisis management plan.
Despite the effectiveness of interventions such as WRAP, clinic-based approaches may pose barriers to participation for some service users. Mobile health (mHealth) interventions use smartphones, wearables, and other mobile devices to support health. Recent evidence shows that mHealth technologies can be used to successfully deliver psychosocial interventions outside the traditional clinic setting and help overcome access barriers (7, 8). A growing body of work supports the feasibility and clinical promise of various mHealth approaches among persons with serious mental illness (914). FOCUS is a smartphone-based illness management system specifically designed for those with serious mental illness. FOCUS provides users with daily self-assessments, illness management practice and intervention content, and Web-based summary reports accessible to an authorized mHealth support specialist. FOCUS leverages smartphone video and audio media players to enhance users’ experience and to “bring the intervention to life” (7).
This article reports qualitative findings from a comparative effectiveness trial comparing FOCUS (9) and WRAP (6). The main outcomes from the trial served as a point of departure for this qualitative analysis. As previously reported, FOCUS and WRAP produced comparable clinical outcomes and both had high satisfaction ratings; individuals assigned to FOCUS commenced the intervention at significantly higher rates compared with those assigned to WRAP (9). Our objective was to integrate qualitative findings with the previously reported main outcomes (10).
We have previously reported on how participants made use of FOCUS in their everyday lives to self-manage mental illness (8). The qualitative study described here aimed to compare experiences with FOCUS and WRAP. We sought to examine whether people with serious mental illness notice and care about specific features of these interventions and how these interventions shape experiences of symptoms, recovery, and quality of life. Qualitative methods facilitated insight into first-person perspectives on the two psychosocial interventions (11). To our knowledge, this study was the first to use qualitative methods to compare an mHealth and a clinic-based illness self-management intervention for serious mental illness.

Methods

A qualitative substudy was nested within the main comparative effectiveness trial, which was conducted between June 2015 and September 2017, to provide additional insight into patient engagement and satisfaction with FOCUS and WRAP and to augment understanding of clinical outcomes through patient narratives regarding the perceived impact of the interventions. The qualitative research design was guided by meaning-centered medical anthropological approaches (15) to elicit in-depth illness narratives and treatment experiences. The study was approved by the Dartmouth College Committee for the Protection of Human Subjects and the University of Washington Institutional Review Board (IRB) and monitored by an independent safety monitoring board at Dartmouth’s Department of Psychiatry.
Individuals were eligible for the main comparative effectiveness trial if they had a chart diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder; were age 18 or older; and had a rating of ≤3 on one of three items that constitute the domination-by-symptoms factor from the Recovery Assessment Scale (16), which indicates a need for services. Individuals were excluded if they had a hearing, vision, or motor impairment that made it impossible to operate a smartphone; had an English reading level below 4th grade; or had received the WRAP or FOCUS intervention in the past 3 years. Participants in the main trial were recruited by 20 clinical teams at Thresholds, a large agency that provides services to people with serious mental illness living in Chicago.
For the qualitative study, we used purposive sampling to select individuals from the main trial with varying levels of engagement with FOCUS and WRAP in order to capture positive and negative sentiments about the interventions. High engagers were those who used the intervention for at least 9 of 12 weeks. Individuals who did not meet these criteria were categorized as low engagers. Potential participants for the qualitative interviews were identified by engagement level prior to recruitment by using attendance data for WRAP and app usage data for FOCUS. Researchers invited individuals by telephone to participate in qualitative interviews. Individuals who expressed interest were scheduled to meet with us. Prior to the interview, we provided detailed information regarding the qualitative study’s purpose, risks, and procedures. Participants gave written signed consent and were compensated $30 for completing the interview. Interviews were conducted with study participants after they had completed the interventions to minimize any potential impact that an in-depth reflection about the intervention might have had on their engagement or satisfaction. Interviews were conducted throughout the study in successive “waves,” mirroring the enrollment pattern of the trial.
The qualitative sample consisted of 31 participants (FOCUS, N=16; WRAP, N=15). Our determination of sample size was guided by expectations for thematic saturation. Although no gold standards exist for determining sample size for qualitative research (17), some research suggests that saturation is typically achieved after 12 to 18 interviews (18). With this in mind, and because we purposively sampled to include persons with a range of engagement, we expected to enroll 30 participants in the qualitative study.
We conducted semistructured interviews to generate a nuanced understanding of participants’ experiences with the interventions. Semistructured interviews were selected as the method of choice because this approach enables researchers to inquire into similar topics across participants while also allowing for flexibility and probing to elicit rich accounts. Interviews were conducted by researchers trained in qualitative methods and with experience working with people with serious mental illnesses. Interview questions were organized into the following domains: overall perspectives on the intervention, engagement with the intervention, FOCUS or WRAP in relation to illness experience, and FOCUS or WRAP in the context of mental health services. Examples of questions include, Thinking back over the past 3 months of participating in [WRAP or FOCUS], what were your overall impressions? What has this experience meant to you? What did you like about [WRAP or FOCUS]? What did you not like about [WRAP or FOCUS]? In what ways did [WRAP or FOCUS] impact how you manage your symptoms?
Interviews produced detailed accounts of how participants engaged with the interventions, what they found useful and liked, and what was challenging about the interventions. The interview guides were constructed to obtain comparable information across the two interventions, but some questions were tailored to FOCUS and some to WRAP. The interview guides were revised through collaborative discussion following the initial round of interviewing to refine questions for clarity and relation to the research aims. Interviews were 45–60 minutes long and were audio recorded; brief field notes were taken, including researchers’ reflections and observations. Audio recordings were transcribed by a transcription service and checked for accuracy by a research assistant.
Three of the authors (E.C.S., G.J., and R.B.) reviewed the first round of transcripts and independently generated a list of initial concepts and categories. Involving multiple analysts strengthens the rigor of the interpretation of qualitative data by facilitating multiple perspectives during analysis (19). On the basis of this review, the study aims, and domains of the interview guide, a codebook of 37 initial codes was developed and used to code the transcripts by using a thematic analytic approach (20). Provisional concepts and patterns identified in the early interviews were used to identify areas of investigation in subsequent interviews (e.g., comparison of the intervention to previous forms of treatment to provide additional insight into impact). Through continued immersion in the data set, we constructed eight additional codes via review and discussion. The final codebook had 45 codes, grouped into 12 domains. For the analysis reported here, we focused on the following domains: indicators of acceptability of the interventions, indicators of unacceptability of the interventions, challenges with the intervention, and impact of the interventions. [A table in an online supplement to this article presents details of the codes and definitions included in each of the domains.] We selected these domains for their relevance in providing insight into patient engagement, satisfaction with the interventions, and perceived impact of the interventions. We used Dedoose, a qualitative analytic software program, to manage and code the data (21). Coding was led by one of the authors (G.J.), with ongoing supervision and review by the lead author (E.C.S.), an experienced qualitative researcher, as a check on trustworthiness. We held regular meetings to discuss and review codes and coded data. If there were questions regarding the application of codes, we were able to resolve via consensus.
Qualitative analysis involves more than coding the data set. Whereas codes consist of labels to capture an idea associated with a segment of data, themes capture common, recurring patterns across the data set. To develop themes, coded excerpts were aggregated in Dedoose into reports. Two authors (E.C.S. and G.J.) independently reviewed and annotated these reports and wrote analytic memos to identify patterns. Analytic memos were shared and subsequently revised and refined into data summary reports that outlined main thematic findings and included emblematic quotations.

Results

Participants

Table 1 summarizes the participants’ demographic characteristics and diagnosis by intervention. The sample included high and low engagers from both interventions. The mean number of weeks in which participants engaged was similar across both interventions, with a mean of 7.86 weeks for WRAP and 8.13 weeks for FOCUS.
TABLE 1. Characteristics of 31 interviewees who had participated in FOCUS or Wellness Recovery Action Planning (WRAP)
 FOCUS (N=16)WRAP (N=15)
CharacteristicN%N%
Gender    
 Male1169960
 Female531640
Race    
 White744533
 Black656960
 ≥1017
Latino ethnicity213213
Education    
 8th grade160
 Some high school425213
 High school diploma or GED744427
 Some college425747
 Bachelor’s degree017
 Master’s degree017
Living status    
 Assisted531427
 With family0427
 Independent1169747
Had used a smartphone before    
 No531640
 Yes1169960
Diagnosis    
 Schizophrenia4250
 Schizoaffective disorder638853
 Bipolar disorder16640
 Major depression53117

Satisfaction: Information, Accessibility, and Community

The high satisfaction ratings previously reported for FOCUS and WRAP were mirrored in positive accounts in the interviews. Most participants detailed positive experiences with both interventions. Participants in FOCUS and in WRAP described how the interventions provided new information about symptoms and coping strategies that they had not received elsewhere in treatment (Table 2). The interviews also revealed potential differences in the reasons underlying high satisfaction with FOCUS and with WRAP. Accessibility of the intervention figured prominently in participants’ accounts of FOCUS. Participants emphasized that FOCUS was a portable tool that they could use for support “on demand.” Most participants expressed that FOCUS’s 24/7 availability was an advantage over other mental health services.
TABLE 2. Illustrative quotes about participants’ satisfaction with FOCUS or Wellness Recovery Action Planning (WRAP)
Theme and 
interventionQuote
New information 
 FOCUS“With FOCUS there was some stuff that was new to me that I didn’t know about . . . and the doctor [in the FOCUS videos] would explain certain situations and I would remember it, and it would help me out with questions I had about what was going on with symptoms and stuff or medications or something. And the FOCUS program gave me enough information, like on different aspects of my own personal situations.” (Participant 41)
 WRAP“[WRAP] taught me about myself, what it’s opened up to me and shown me some of the available resources that are out there . . . whereas the other groups that I had: ‘Okay, we’re just going to go talk about managing anxiety. You know, there’s five simple things to do to manage anxiety.’ They’re always the five same things. It’s like you never learn anything. . . . No light bulbs go off or anything like that, whereas in WRAP, some light bulbs went off and some new things.” (Participant 6)
Accessibility 
 FOCUS“[FOCUS] kept going with you everywhere you go. . . . No matter where you were at, what type of mood you come in, you can just type in something like that. I’m like, ‘Wow.’ And that’s what I liked about it—you could take it with you. . . . Help everywhere you go” (Participant 17); “I can go into FOCUS any time of day, I can’t, like, go to my case manager at midnight and check in with him, you know? But I can go into FOCUS any time of the night, and it’s like talking to someone.” (Participant 134)
Community 
 WRAP“What did I like most about [WRAP]? Being there with everyone, listening to everyone's story, and then getting the chance, you know, to share my story and my experience in life” (Participant 53); “[WRAP] made me realize I'm not in this alone. You know. There's a lot of people like me and that it made my awareness just come out.” (Participant 33)
In the accounts of WRAP participants, descriptions of community were especially salient. Participants found a supportive community of individuals with shared experiences of mental illness. Participants described feeling a “tightness to the group,” and many noted that WRAP made them realize that they “weren’t alone.” In some cases, WRAP members continued to meet with each other after the program had officially ended.

Treatment Commencement: Groups Versus Phones

The finding that participants who used FOCUS commenced the intervention at significantly higher rates, compared with WRAP participants, may be linked to the strongly negative attitudes toward group-based interventions expressed by some participants who had been randomly assigned to WRAP (Table 3). Those who did not attend any WRAP sessions reported making this decision immediately following randomization. For some, the decision not to begin attending WRAP sessions was based on competing priorities, such as seeking housing. But for many, the decision was based on the participant’s dislike of group-based interactions. In contrast, those who were randomly assigned to FOCUS were generally excited about the intervention and about receiving a smartphone for the 12 weeks of the intervention.
TABLE 3. Illustrative quotes about the effect of phone and group interventions on treatment commencement with FOCUS or Wellness Recovery Action Planning (WRAP)
Theme and 
interventionQuote
Phone 
 FOCUS“I was [hoping for] the phone because for some reason it just sounded like a good experience . . . something new that I could possibly get involved in. . . . It went by a lot easier that way too. . . . The fact that I was at home and I could carry the phone with me.” (Participant 41)
Group 
 WRAP“I’m just not used to being in a group with a whole bunch of people telling their story.” (Participant 12)

Impact of the Interventions: New Skills, Fresh Insights

The comparable clinical outcomes of FOCUS and WRAP were reflected in many participants’ narratives describing the positive impact of the interventions on their mental health recovery. Participants in both FOCUS and WRAP described shifts in their perspectives that prompted new insights about mental illness and themselves (Table 4). Participants also described specific skills they had gained to manage their illnesses. Many described how FOCUS had helped them develop skills to navigate difficult social situations and become more open and patient with their peers. Many participants stated that the new skills they learned in FOCUS helped them understand how minor changes in their routine might have an impact on their symptoms. FOCUS helped some participants establish short-term, directed goals related to self-care tasks (e.g., reading, housekeeping, organization, and exercising) and community activities (e.g., volunteer work). Some described being motivated by FOCUS to become further involved in their communities.
TABLE 4. Illustrative quotes about the impact of FOCUS or Wellness Recovery Action Planning (WRAP)
Theme and 
interventionQuote
Fresh insights about mental illness 
 FOCUS“[FOCUS] made me hope I can achieve more mentally and physically and what have you. It gave me insight into some successful endeavors and positive strength.” (Participant 140)
 WRAP“[WRAP] inspired me to wanna find other things to do other than just sitting around the house and being a monotone person. I actually wanna meet [people]. . . . I'm more active. I'm more independent” (Participant 92); “I would say my recovery has been a struggle and it’s still a struggle. We’re still trying different medicines and stuff like that and that’s really challenging and frustrating to go through, taking this for 8 weeks to see if it works. . . . But the hope that things will get better and that there is a place of stability that can be achieved. Before the WRAP group, I didn’t really have any hope and encouragement in thinking that things will get better. . . . But learning there are things I can do daily to improve my mood and stuff like that . . . I think that’s what’s instilled the hope is realizing that there’s a lot more than I can control and have an impact on. You know, it’s not just I’m waiting for somebody else to do something. . . . So, it’s thinking about those things that you can do on a daily basis that make you feel better” (Participant 6); “With the WRAP, it's more you're enacting. You're more a participant, and you're more involved with your own recovery” (Participant 136); Interviewer: “What would you say is different today from what you were doing before you started WRAP 12 weeks ago?” Interviewee: “I’m more conscious in my daily interactions with people and how important they can be to me and me to them . . . realizing that that personal touch and that personal connection between people can be a vital tool for my mental health.” (Participant 6)
New skills 
 FOCUS“I liked what it would say about socialization, because being on the South Side, you have to know how to socialize and deal with people. Being on medication, they say we get the stigma. . . so we may get mistreated. . . . I’m high functioning, but I got to deal with the outside world. I have to know who to communicate to, who not to. . . . With FOCUS it says how to do it, how not to do it, give them a chance, don’t be scared of people, you know” (Participant 56); “I'm more open with people. . . . I'm not so quick to just like shut everybody out, which is sometimes what I still do” (Participant 108); “It helped me to learn a few things I didn’t even think about. . . . My sleep . . . can be like up and down, up and down. There was one patch where I only had like four hours of sleep. . . . Light in the room, I didn’t realize that could impact sleep. As far as caffeine that’s another thing that was brought up. . . . I learned not to drink caffeine so late at night” (Participant 108); “It motivated me in many ways. . . . It was drawing me in with the feedback. . . . It made me more motivated to go to other groups like [peer recovery center]. . . . It gave me a craving to expound cause I’m very much bashful, when I’m around individuals I know. . . . [FOCUS] freed me to go further” (Participant 67); “I would say this is the first time I’ve seen anybody take an interest in asking me what are, what is it like when you’re well? What are your goals of wellness? What does wellness look like to you? What are your triggers? . . . How can you help me get to some place [in recovery] if you don’t know where it is? You haven’t even bothered to ask, you know. Um, yeah, that’s a huge difference.” (Participant 6)
WRAP participants described how the WRAP toolbox helped them learn about new coping strategies and about how to identify triggers and how to plan in the event of a relapse. Participants appreciated the practical side of learning new skills through WRAP (e.g., having a daily maintenance plan that served as a checklist for the day). Some experienced a change in how they interacted with others. One participant elaborated on how WRAP was a turning point in realizing that there is hope for recovery. Others noted that WRAP provided a unique opportunity for reflection on recovery goals, preferences, and processes. Similarly, some stated that WRAP encouraged them to be active participants in their own recovery.

Negative Experiences and Challenges With FOCUS and WRAP

Although both interventions had high overall satisfaction ratings, qualitative interviews revealed some potentially problematic aspects of the interventions (Table 5). Among the few participants who expressed negative views of FOCUS, repetition of content over time was a concern. One participant noted that he refrained from using the app because of repetition. Others stated that they had already learned many of the tips, skills, and lessons offered in FOCUS in the context of other mental health services. One participant expressed that the app was “too brief” and “too clinical” and wished it was “just a touch more personalized.” This participant suggested tailoring FOCUS to different stages of recovery.
TABLE 5. Illustrative quotes about negative experiences and challenges with FOCUS or Wellness Recovery Action Planning (WRAP)
Theme 
and interventionQuote
Repetition 
 FOCUS“The options were few. Then, the same input. . . . You know I think it should be different when you call different times. It shouldn’t be the same thing they tell you to do. . . . I think there should be a little more variety and that was the only thing” (Participant 134); “At some point I just dropped off completely because it just . . . you can only do the same thing so many times . . . before it becomes so routine” (Participant 60); “Yes, I did already know those things. And it didn’t really help, you know. . . . It was feeling like it’s a waste, you know?” (Participant 10)
Lack of personalization 
 FOCUS“I am in sort of the advanced stage of recovery. The composite of choices was a bit dumbed down. . . . So [FOCUS] might have to target specific graduations of the program. . . . I would say at least three different levels. . . . Level one would be persons at the beginning of their recovery. Let’s say they’ve just been discharged from a facility or just was diagnosed . . . starting to learn about the illness. Level two is in the middle. They’ve reached a point where they’re getting more self-awareness or understanding of the illness and how to cope with certain symptomatic episodes. And then you have the advanced level, where that would be the one that would be the deepest.” (Participant 60)
Lack of face-to-face connection and community 
 FOCUS“It’s more real when you’re face to face with someone. That’s the only difference with this. If you have a face, then it can feel better than the phone can” (Participant 17); “Oh, I like to just, rather than the FOCUS, I just like rather talk to person, people in person.” (Participant 106)
Group dynamics 
  WRAP“I was like, ‘Wow. I really don't like group sessions.’ Yeah. I was like, ‘I hope, I hope.’ I was hoping I was getting the phone. It would have been easier” (Participant 12); “I was uncomfortable somewhat with the—sometimes during a few of the weeks different members of those other groups were going through some personal problems that they were sharing with the group. It was a little uncomfortable” (Participant 24); “A few parts I didn’t care for, someone said something like I had interrupted them or called them out, and he thought it was rude. . . . I was a little on edge, I felt a little hate from others. . . . I felt like I was targeted in some way along those lines. The staff made me feel more comfortable. I was relieved that they were there. It didn’t seem like there was much connection between me and the others in the group.” (Participant 94)
Commitment 
  WRAP“That was really the only time I had a problem was when people weren't showing up who were supposed to be. . . . If you say you're gonna do something, do it. . . . So, it seems like that some people were dropping in and out and . . . it made you question whether or not your business was being put out in the world, you know. . . . Like, how, how true is this person to this program?” (Participant 92)
Privacy 
  WRAP“Well, I feel more comfortable sharing with my case manager things about my relationship of my father with myself. . . . Very personal. . . . I'm more comfortable sharing with one person. Yeah, [with] my case manager, yeah.” (Participant 24)
Participants also reflected on how the interventions compared with their current mental health services. In this context, some identified a lack of a face-to-face connection as a disadvantage with FOCUS. A few participants said that the lack of a community or group setting on the app was problematic and that they preferred to discuss their mental health in person. When asked to compare WRAP with his or her current mental health services, one participant noted that certain personal experiences would be more comfortably shared with a case manager rather than in a group setting.
Participants who identified negative aspects of WRAP focused on challenges pertaining to group dynamics. One participant expressed a clear dislike of groups and a preference for a phone-based intervention. For some, sharing or listening to personal experiences in a group was uncomfortable. Others were bothered by difficult personalities in the group, describing fellow participants as “very rude” or as behaving like a “jerk” during sessions. Another participant described challenging interactions with other group participants but noted that these negative experiences were balanced by positive connections with staff. A few participants also expressed their sense that some group members were not committed to the goals of WRAP.

Discussion

We applied qualitative methods to provide additional insight into the main outcomes of a comparative effectiveness trial of mHealth and clinic-based self-management interventions for persons with serious mental illness (9). Overall, participant narratives provided evidence that both interventions were well received by many and that the interventions provided opportunities to learn new illness management skills. Participants were drawn to the hallmark characteristics of the two interventions: the 24/7 accessibility of FOCUS and the social support and peer learning in WRAP. Although the high overall satisfaction ratings for both interventions are promising and many participants described the interventions as having had a meaningful impact, qualitative analyses also identified aspects of the interventions that participants found unhelpful, problematic, or challenging. A few participants noted dissatisfaction with repetitive content and a lack of personal connection in FOCUS. mHealth interventions such as FOCUS could benefit from periodic content updates or staggered unlocking of content based on the user’s evolving needs. Providing mHealth users with opportunities to integrate their own content into the intervention (e.g., functionality to upload photos of loved ones, insert individually selected inspirational quotes, and integrate favorite music into modules) may help increase relevance and personalization.
Interview accounts also suggested that the group-based structure of WRAP seems especially preference sensitive. Participants with negative attitudes toward groups did not initiate WRAP. More rigorous screening to determine goodness of fit for the group intervention may help prevent such experiences. In contrast, the smartphone-based intervention delivery for FOCUS—accessed in one’s own environment versus administered in a treatment center, largely automated versus person delivered, and on demand versus scheduled—was attractive to some participants and had few barriers to entry. Combined with the quantitative results of the comparative effectiveness trial (9), the findings suggest that clinical programming and policy efforts should support continued development of mHealth solutions and innovation in digital health payment and reimbursement models so that individuals gain opportunities to benefit from mental health resources that they might otherwise not receive through standard care.
The study had some limitations. It was designed to enhance the credibility and transferability of findings (22) by sampling participants with a range of engagement levels and until saturation was reached and by involving multiple researchers to allow for multiple perspectives (19, 23). However, the findings have limited generalizability because of the small sample and the single site. In addition, interviewing participants only once may have limited our ability to build rapport, and responses may have reflected some social desirability bias. In a few cases, participants were highly symptomatic. Interviews may not have been the best approach in such circumstances.

Conclusions

We applied a qualitative approach to gain further insight into the comparable outcomes previously reported for illness self-management interventions delivered via smartphone or a clinic-based group. The interview accounts of the two interventions provided additional evidence to support expanding the range of services available to individuals with serious mental illnesses to include both traditional and technology-based approaches.

Supplementary Material

File (appi.ps.201900110.ds001.pdf)

References

1.
Kessler RC, Barker PR, Colpe LJ, et al: Screening for serious mental illness in the general population. Arch Gen Psychiatry 2003; 60:184–189
2.
Strauss GP, Harrow M, Grossman LS, et al: Periods of recovery in deficit syndrome schizophrenia: a 20-year multi-follow-up longitudinal study. Schizophr Bull 2010; 36:788–799
3.
Davidson L, Schmutte T, Dinzeo T, et al: Remission and recovery in schizophrenia: practitioner and patient perspectives. Schizophr Bull 2008; 34:5–8
4.
Deegan PE: Recovery: the lived experience of rehabilitation. Community Ment Health J 1988; 11:11–19
5.
Mueser KT, Corrigan PW, Hilton DW, et al: Illness management and recovery: a review of the research. Psychiatr Serv 2002; 53:1272–1284
6.
Copeland ME: Wellness Recovery Action Plan. Brattleboro, VT, Peach Press, 1999
7.
Ben-Zeev D, Brian RM, Aschbrenner KA, et al: Video-based mobile health interventions for people with schizophrenia: bringing the “pocket therapist” to life. Psychiatr Rehabil J 2018; 41:39–45
8.
Jonathan G, Carpenter-Song E, Brian R, et al: Life with FOCUS: a qualitative evaluation of the impact of a smartphone intervention on people with serious mental illness. Psychiatr Rehabil J 2019; 42:182–189
9.
Ben-Zeev D, Brian RM, Jonathan G, et al: Mobile health (mHealth) versus clinic-based group intervention for people with serious mental illness: a randomized controlled trial. Psychiatr Serv 2018; 69:978–985
10.
Fetters MD, Curry LA, Creswell JW: Achieving integration in mixed methods designs: principles and practices. Health Serv Res 2013; 48:2134–2156
11.
Pope C, Mays N: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ 1995; 311:42–45
12.
Naslund JA, Marsch LA, McHugo GJ, et al: Emerging mHealth and eHealth interventions for serious mental illness: a review of the literature. J Ment Health 2015; 24:321–332
13.
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
14.
Berry N, Lobban F, Emsley R, et al: Acceptability of interventions delivered online and through mobile phones for people who experience severe mental health problems: a systematic review. J Med Internet Res 2016; 18:e121
15.
Kleinman A: The Illness Narratives: Suffering, Healing, and the Human Condition. New York, Basic Books, 1988
16.
Corrigan PW, Salzer M, Ralph RO, et al: Examining the factor structure of the Recovery Assessment Scale. Schizophr Bull 2004; 30:1035–1041
17.
Sandelowski M: Sample size in qualitative research. Res Nurs Health 1995; 18:179–183
18.
Guest G, Bunce A, Johnson L: How many interviews are enough? An experiment with data saturation and variability. Field Methods 2006; 18:59–82
19.
Whitley R, Crawford M: Qualitative research in psychiatry. Can J Psychiatry 2005; 50:108–114
20.
Braun V, Clarke V: Using thematic analysis in psychology. Qual Res Psychol 2006; 3:77–101
21.
Dedoose, Version 8.1.8. Los Angeles, SocioCultural Research Consultants, 2018
22.
Byrne MM: Evaluating the findings of qualitative research. AORN J 2001; 73:703–706
23.
Fusch PI, Ness LR: Are we there yet? Data saturation in qualitative research. Qual Rep 2015; 20:1408–1416

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Pages: 49 - 56
PubMed: 31615368

History

Received: 26 February 2019
Revision received: 18 June 2019
Accepted: 29 July 2019
Published online: 16 October 2019
Published in print: January 01, 2020

Keywords

  1. Community mental health services
  2. Research/service delivery
  3. Serious mental illness
  4. Illness self-management
  5. Mobile health
  6. Qualitative research

Authors

Details

Elizabeth Carpenter-Song, Ph.D. [email protected]
Department of Anthropology, Dartmouth College, Hanover, New Hampshire (Carpenter-Song); Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Jonathan); Behavioral Research in Technology and Engineering (BRiTE) Center, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Brian, Ben-Zeev).
Geneva Jonathan, B.A.
Department of Anthropology, Dartmouth College, Hanover, New Hampshire (Carpenter-Song); Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Jonathan); Behavioral Research in Technology and Engineering (BRiTE) Center, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Brian, Ben-Zeev).
Rachel Brian, M.P.H.
Department of Anthropology, Dartmouth College, Hanover, New Hampshire (Carpenter-Song); Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Jonathan); Behavioral Research in Technology and Engineering (BRiTE) Center, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Brian, Ben-Zeev).
Dror Ben-Zeev, Ph.D.
Department of Anthropology, Dartmouth College, Hanover, New Hampshire (Carpenter-Song); Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Jonathan); Behavioral Research in Technology and Engineering (BRiTE) Center, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Brian, Ben-Zeev).

Notes

Send correspondence to Dr. Carpenter-Song ([email protected]).

Competing Interests

Dr. Ben-Zeev has a financial interest in the FOCUS technology described in this article. He reports serving as a consultant for Equility and has an intervention content licensing agreement with Pear Therapeutics. The other authors report no financial relationships with commercial interests.

Funding Information

Patient-Centered Outcomes Research Institutehttp://dx.doi.org/10.13039/100006093: PCORI Research Award CER-1403-11403
Research reported in this article was supported by research award CER-1403-11403 from the Patient-Centered Outcomes Research Institute (PCORI). The views and statements in this article are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its Board of Governors, or Methodology Committee. The authors gratefully acknowledge the contributions of staff and service recipients at Thresholds, Chicago.

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.

Format
Citation style
Style
Copy to clipboard

View Options

View options

PDF/EPUB

View PDF/EPUB

Get Access

Login 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 login
Purchase Options

Purchase this article to access the full text.

PPV Articles - Psychiatric Services

PPV Articles - Psychiatric Services

Not a subscriber?

Subscribe Now / Learn More

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.).

Media

Figures

Other

Tables

Share

Share

Share article link

Share