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Abstract

Objective:

Mobile technologies, such as smartphones, can improve health services by delivering assessments and interventions that reach people in their daily lives. There is, however, disagreement regarding whether people with serious mental illness make meaningful use of mobile technology and whether interventions that rely on mobile technology should be tailored for this population.

Methods:

At two clinics, 249 people with serious mental illness were interviewed regarding mobile phone use, and their cognitive functioning was assessed.

Results:

Mobile phones were used by 86% of participants, including 60% who used a smartphone. Phones were used for messaging by 81%, Internet by 52%, e-mail by 46%, and applications by 45%. Individuals who were older, had a persistent psychotic disorder rather than bipolar disorder, received disability income, or had worse neurocognitive functioning were less likely to own a smartphone (χ2=52.7, p<0.001).

Conclusions:

Most patients with serious mental illness owned a mobile phone; a majority owned a smartphone. Developers should consider tailoring mobile interventions for psychosis and cognitive deficits.

HIGHLIGHTS

Rates of mobile phone and smartphone use by people with serious mental illness were similar to those of the general population.
Phones were commonly used for text messaging, social media, Internet, e-mail, and applications.
Individuals were less likely to own a smartphone if they were older, had a persistent psychotic disorder rather than bipolar disorder, received disability income, or had worse neurocognitive functioning.
Surveys indicate that 95% of U.S. adults own a mobile phone, and three-quarters own a smartphone (1). Numerous evidence-based interventions use mobile messaging or applications (apps) to deliver services for persistent health conditions, such as smoking, obesity, or diabetes (2). Although there is enthusiasm regarding mobile assessments and interventions for people with serious mental illness, the research and dissemination of these technologies has been slow. There continues to be substantial skepticism and uncertainty among researchers and clinicians regarding whether people with serious mental illness use mobile phones or smartphones, whether they can use the same mobile interventions as the general population, and whether it would be beneficial to tailor apps to meet the specific needs of this population (3).
It is often difficult to implement evidence-based mental health treatments, and patients often do not use effective treatments (4). The dissemination of mobile phones provides an opportunity for monitoring and intervention outside the clinic setting, one that enables contact with patients when and where it is convenient for them. Interventions that use mobile technology could promote health behavior change, improve the effectiveness of interventions, and reach large populations (2). There have been studies of mobile phone ownership among people with serious mental illness (5). Most of these studies, however, were conducted before the rapid dissemination of smartphones and contribute little information about smartphone use. Research has found that about 86% of people with schizophrenia own a mobile phone (6). Studies have also been conducted on the feasibility of using mobile phones as part of treatment for people with serious mental illness (7). These studies have found that mobile interventions are feasible and can improve the therapeutic alliance (8). Attention has turned more recently to smartphone use. It is not clear how often individuals with serious mental illness use smartphones, for what functions, and whether characteristics of this population limit the use of smartphones.
Some issues specific to the population with serious mental illness may impede smartphone use. People with serious mental illness have conditions that are often accompanied by socioeconomic disadvantage, limited education, symptoms, and cognitive impairments that may affect phone use. Socioeconomic barriers to smartphone use include limited income, although the federal Lifeline program offers phones, including smartphones, to most people with serious mental illness at low cost. Cognitive barriers include pervasive problems with speed of processing, attention, working memory, verbal learning and memory, visual learning and memory, and problem solving. In-person interventions have been tailored to accommodate cognitive deficits and literacy issues (9), but mobile interventions have not been consistently tailored for people with serious mental illness (10).
In this study of mobile phone use among individuals with serious mental illness at two mental health clinics, we sought to understand the use of mobile phones and smartphones in this population. We examined whether and how these patients use their phones, which phone functions they use, and how phone ownership varied by demographic characteristic, education, psychiatric diagnosis, disability, and level of cognitive functioning.

Methods

Participants were recruited as part of a larger project studying interventions intended to improve the diet and activity of overweight individuals with serious mental illness (11). Recruitment occurred at two large mental health clinics, one operated by the Department of Veterans Affairs (VA) and one by the Los Angeles County Department of Mental Health. Individuals in treatment were eligible for the study if they were overweight and had a diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder with psychosis, or serious persistent posttraumatic stress disorder. The study was approved by the institutional review boards and human subjects committees of the involved institutions. Participants provided written informed consent. Enrollment occurred between March 1, 2012, and April 11, 2014. Research staff interviewed participants regarding demographic characteristics, education level, Internet access, and receipt of disability income as well as the type of mobile phone they own and which functions and apps they use on their phone. Smartphones were identified by determining the specific manufacturer and model of the phone. Patients’ cognitive functioning was measured with the Digit Symbol Substitution Test to assess neurocognitive speed of processing (12) and the Hopkins Verbal Learning Test Revised (13), measurements that have been associated with impairment in functioning of people with serious mental illness (14). Cognitive functioning scores were transformed to general population norms (12, 13). We used a multiple logistic regression to examine the effect of participant characteristics on both mobile phone use and smartphone use.
Semi-structured interviews were completed with a random subset of 48 study participants. Respondents were asked about their use of mobile phones and interest in mobile phone apps. The interviews were audio recorded and transcribed. We used Atlas.ti to organize the analyses into themes. Two research team members (N.N. and T.O.) used open coding to label text segments of interest. Transcripts were coded to the interview questions and for any additional pertinent factors emerging during coding. Discrepancies in coding were discussed by the two research team members and reconciled after coding. Overarching themes were identified from the open coding through an iterative process.

Results

A total of 326 individuals were enrolled in the larger study, including 276 at the VA clinic and 50 at the county clinic. There were 77 participants lost to follow-up who were not interviewed about mobile phone usage, leaving 249 participants for the mobile phone analyses. Mean±SD age was 54±9.8; 224 (90%) were male, 108 (43%) were white, 102 (41%) were black, 28 (13%) were Hispanic, and six (2%) were Native American. The remaining participants were of mixed or other race. There were 115 (46%) participants with schizophrenia or schizoaffective disorder, 58 (23%) with bipolar disorder, 45 (18%) with persistent posttraumatic stress disorder (PTSD), and 31 (12%) with other persistent psychotic disorders. Of the participants, 79 (32%) had a high school education or less, 159 (64%) had any college education, and 11 (4%) had any graduate school education; 138 (55%) received Social Security or VA disability payments. Participants’ mean transformed cognition score on the Hopkins Verbal Learning Test was 34.8±7.6 and score on the Digit Symbol Substitution Test was 37.4±11.5. Both these means are more than one standard deviation below population norms.
Of the participants, 213 (86%) owned a mobile phone and 149 (60%) owned a smartphone. The rates of mobile phone and smartphone ownership were similar at the VA clinic and the county clinic. Smartphones were owned by 44 (77%) people with bipolar disorder, 20 (77%) with other psychoses, 34 (76%) with PTSD, and 51 (44%) with schizophrenia or schizoaffective disorder. Of the smartphones, 105 (71%) were an Android, 40 (27%) were an iPhone, and four (3%) were a Blackberry. Of the participants with a mobile phone, 173 (81%) used it for text messaging, 127 (60%) as a camera, 111 (52%) for Internet access, 99 (45%) for e-mail, 96 (45%) for apps, 87 (41%) for music, 86 (40%) for a calendar, 61 (29%) for an alarm, and 49 (23%) for a calculator. When asked which app they used most frequently, the participants responded, in descending order of frequency, social media, videos, games, music, and maps. The second most frequently used apps were those for e-mail, social media, music, videos, games, and news.
Table 1 presents associations between participant characteristics and ownership of mobile phones and smartphones derived from our regression analyses. With the first model, we found that individuals were less likely to own any mobile phone (χ2=33.5, p<0.001) if they were male, received disability income, or had worse neurocognitive speed of processing. With the second model, we found that individuals were less likely to own a smartphone (χ2=52.7, p<0.001) if they were older, had schizophrenia (or other persistent psychotic disorder) rather than bipolar disorder, received disability income, or had worse neurocognitive speed of processing.
TABLE 1. Correlations between characteristics of 249 participants with serious mental illness and the odds of owning a mobile phonea
VariableOR95% CIp
Owns any mobile phone   
 Age (years).97.92–1.02.25
 Female (reference: male)5.991.54–23.34.01
 Education (reference: any graduate school)   
  High school graduate or less1.34.11–16.89.70
  Any college1.00.08–11.34.83
 Diagnosis (reference: bipolar disorder)   
  Persistent PTSD.31.05–2.05.52
  Schizophrenia.23.05–1.17.12
 Receives disability income (reference: no disability income).15.05–.40<.001
 Digit Symbol Substitution Test cognitive score (processing speed)1.051.01–1.10.02
 Hopkins Verbal Learning Test cognitive score.98.92–1.06.68
Owns a smartphone   
 Age (years).92.88–.96<.001
 Female (reference: male)1.67.53–5.29.38
 Education (reference: any graduate school)   
  High school graduate or less1.15.16–8.35.93
  Any college1.47.22–9.94.56
 Diagnosis (reference: bipolar disorder)   
  Persistent PTSD.99.31–3.17.19
  Schizophrenia.28.11–.69<.001
 Receives disability income (reference: no disability income).38.19–.76.006
 Digit Symbol Substitution Test cognitive score1.041.01–1.07.01
 Hopkins Verbal Learning Test cognitive score.97.92–1.02.25
a
Results are from the multiple regression analysis.
Our qualitative analyses resulted in thematic categories of facilitators, barriers, and preferences regarding mobile phones and smartphones. Facilitators of the use of mobile interventions included convenience and increased access to services. Although some respondents were hesitant about using computers, there was general enthusiasm for mobile apps. There was substantial interest in obtaining a smartphone and learning more about how to use smartphones. Participants believed that smartphones could provide them with structure, support, and services between clinic visits. Barriers to use included the costs of smartphones and data plans, concerns about privacy and security, limited experience and comfort with technology and apps, and having an old phone with limited capacity. The participant responses suggested that mobile interventions that consider issues specific to this population could be more likely to be used by people with serious mental illness and, therefore, more likely to be effective.

Discussion

The rapid increase in the rate of smartphone use has also occurred among the population with serious mental illness, with growth trends and ownership rates comparable to those of the general population. When the data in this study were collected, about 90% of U.S. adults owned a mobile phone and 55% owned a smartphone. In this sample with serious mental illness, we found similar overall rates of use. The participants used mobile phone messaging and smartphone apps frequently. This use provides an opportunity to enhance disease management by extending health interventions beyond the reach of traditional care settings. Mobile phones can be used to deliver content that is intensive, engaging, accessible, and tailored to the needs of particular patient populations. Competing demands on time (e.g., work, school, care of children and other dependents) and other barriers (e.g., transportation in urban or rural areas) can make it difficult for patients to access services during clinic hours. Mobile services can reduce the need for patients to visit mental health clinics and allow services to be brought to patients at their convenience. Although technology has revolutionized the delivery of many health care services, mental health services remain largely office based.
In other areas of health care, the introduction of patient-reported outcomes has improved treatments and outcomes and has driven measurement-based care. In mental health, there have been calls for similar interventions, as well as for apps and messaging, but questions remain regarding the use of these methods with people who have serious mental illness. Some clinicians and researchers have been concerned this population cannot use mobile phones or smartphones productively. Others believe that people with serious mental illness are able to use the same apps and interventions as populations without serious mental illness. In this study of people with serious mental illness, we found that a large proportion of the participants used mobile phones and smartphones and were interested in mobile interventions. Limitations of this study included that our sample consisted only of patients who were in treatment in one urban area, were overweight, and were willing to participate in intervention research. Therefore, the participants may not be representative of the national population with serious mental illness. Also, although Lifeline is a national program that can provide low-cost mobile phone access, people with low incomes may face other barriers to access. In this population, certain characteristics, including being determined to be disabled, having schizophrenia, or having cognitive impairment, had a meaningful impact on rates of smartphone ownership. Mobile interventions can be developed that accommodate these characteristics, and such tailoring could strengthen the impact of the interventions.

Conclusions

In this population of people with serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, major depression with psychosis, and severe persistent PTSD), we found rates of ownership and use of smartphones that were similar to those of the general population. Opportunities exist for researchers, clinicians, and technology developers to address serious mental illness through mobile interventions delivered via smartphone. Studies of the implementation and effectiveness of mobile interventions that accommodate the cognitive, literacy, and financial characteristics of populations with serious mental illness are needed.

References

1.
Mobile Fact Sheet. Washington, DC, Pew Research Center, 2018. https://www.pewinternet.org/fact-sheet/mobile/. Accessed April 8, 2019
2.
Free C, Phillips G, Galli L, et al: The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS Med 2013; 10:e1001362
3.
Opportunities and Challenges of Developing Information Technologies on Behavioral and Social Science Clinical Research. Rockville, MD, National Institute of Mental Health, National Advisory Mental Health Council, 2018. https://www.nimh.nih.gov/about/advisory-boards-and-groups/namhc/reports/opportunities-and-challenges-of-developing-information-technologies-on-behavioral-and-social-science-clinical-research.shtml. Accessed April 8, 2019
4.
Young AS, Cohen AN, Miotto KA: Improving the quality of care for serious mental illness; in Quality Improvement in Behavioral Health. Edited by O’Donohue W, Maragakis A. Cham, Switzerland, Springer International Publishing, 2016
5.
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
6.
Miller BJ, Stewart A, Schrimsher J, et al: How connected are people with schizophrenia? Cell phone, computer, email, and social media use. Psychiatry Res 2015; 225:458–463
7.
Torous J, Haim A: Dichotomies in the development and implementation of digital mental health tools. Psychiatr Serv 2018; 69:1204–1206
8.
Bell IH, Lim MH, Rossell SL, et al: Ecological momentary assessment and intervention in the treatment of psychotic disorders: a systematic review. Psychiatr Serv 2017; 68:1172–1181
9.
Daumit GL, Dickerson FB, Wang N-Y, et al: A behavioral weight-loss intervention in persons with serious mental illness. N Engl J Med 2013; 368:1594–1602
10.
Rotondi AJ, Eack SM, Hanusa BH, et al: Critical design elements of e-health applications for users with severe mental illness: singular focus, simple architecture, prominent contents, explicit navigation, and inclusive hyperlinks. Schizophr Bull 2015; 41:440–448
11.
Young AS, Cohen AN, Goldberg R, et al: Improving weight in people with serious mental illness: the effectiveness of computerized services with peer coaches. J Gen Intern Med 2017; 32(suppl 1):48–55
12.
Smith A: Symbol Digit Modalities Test (SDMT) Manual, revised. Los Angeles, Western Psychological Services, 1982
13.
Cherner M, Suarez P, Lazzaretto D, et al: Demographically corrected norms for the Brief Visuospatial Memory Test-revised and Hopkins Verbal Learning Test-revised in monolingual Spanish speakers from the U.S.-Mexico border region. Arch Clin Neuropsychol 2007; 22:343–353
14.
Kern RS, Gold JM, Dickinson D, et al: The MCCB impairment profile for schizophrenia outpatients: results from the MATRICS psychometric and standardization study. Schizophr Res 2011; 126:124–131

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Pages: 280 - 283
PubMed: 31744429

History

Received: 18 April 2019
Revision received: 28 August 2019
Accepted: 9 September 2019
Published online: 20 November 2019
Published in print: March 01, 2020

Keywords

  1. Mental illness and alcohol/drug abuse
  2. cell phone
  3. smartphone
  4. mobile applications
  5. Psychotic Disorders
  6. bipolar disorder

Authors

Details

Alexander S. Young, M.D., M.S.H.S. [email protected]
Veterans Greater Los Angeles Healthcare System, Los Angeles (Young, Cohen, Oberman, Olmos-Ochoa); Department of Psychiatry, University of California, Los Angeles (Young, Cohen, Whelan); Veterans Long Beach Healthcare System, Long Beach, California (Niv); Los Angeles County Department of Mental Health, Los Angeles (Nowlin-Finch); Veterans Maryland Healthcare System, Baltimore (Goldberg).
Amy N. Cohen, Ph.D.
Veterans Greater Los Angeles Healthcare System, Los Angeles (Young, Cohen, Oberman, Olmos-Ochoa); Department of Psychiatry, University of California, Los Angeles (Young, Cohen, Whelan); Veterans Long Beach Healthcare System, Long Beach, California (Niv); Los Angeles County Department of Mental Health, Los Angeles (Nowlin-Finch); Veterans Maryland Healthcare System, Baltimore (Goldberg).
Noosha Niv, Ph.D.
Veterans Greater Los Angeles Healthcare System, Los Angeles (Young, Cohen, Oberman, Olmos-Ochoa); Department of Psychiatry, University of California, Los Angeles (Young, Cohen, Whelan); Veterans Long Beach Healthcare System, Long Beach, California (Niv); Los Angeles County Department of Mental Health, Los Angeles (Nowlin-Finch); Veterans Maryland Healthcare System, Baltimore (Goldberg).
Nancy Nowlin-Finch, M.D.
Veterans Greater Los Angeles Healthcare System, Los Angeles (Young, Cohen, Oberman, Olmos-Ochoa); Department of Psychiatry, University of California, Los Angeles (Young, Cohen, Whelan); Veterans Long Beach Healthcare System, Long Beach, California (Niv); Los Angeles County Department of Mental Health, Los Angeles (Nowlin-Finch); Veterans Maryland Healthcare System, Baltimore (Goldberg).
Rebecca S. Oberman, M.P.H., M.S.W.
Veterans Greater Los Angeles Healthcare System, Los Angeles (Young, Cohen, Oberman, Olmos-Ochoa); Department of Psychiatry, University of California, Los Angeles (Young, Cohen, Whelan); Veterans Long Beach Healthcare System, Long Beach, California (Niv); Los Angeles County Department of Mental Health, Los Angeles (Nowlin-Finch); Veterans Maryland Healthcare System, Baltimore (Goldberg).
Tanya T. Olmos-Ochoa, Ph.D., M.P.H.
Veterans Greater Los Angeles Healthcare System, Los Angeles (Young, Cohen, Oberman, Olmos-Ochoa); Department of Psychiatry, University of California, Los Angeles (Young, Cohen, Whelan); Veterans Long Beach Healthcare System, Long Beach, California (Niv); Los Angeles County Department of Mental Health, Los Angeles (Nowlin-Finch); Veterans Maryland Healthcare System, Baltimore (Goldberg).
Richard W. Goldberg, Ph.D.
Veterans Greater Los Angeles Healthcare System, Los Angeles (Young, Cohen, Oberman, Olmos-Ochoa); Department of Psychiatry, University of California, Los Angeles (Young, Cohen, Whelan); Veterans Long Beach Healthcare System, Long Beach, California (Niv); Los Angeles County Department of Mental Health, Los Angeles (Nowlin-Finch); Veterans Maryland Healthcare System, Baltimore (Goldberg).
Fiona Whelan, M.S.
Veterans Greater Los Angeles Healthcare System, Los Angeles (Young, Cohen, Oberman, Olmos-Ochoa); Department of Psychiatry, University of California, Los Angeles (Young, Cohen, Whelan); Veterans Long Beach Healthcare System, Long Beach, California (Niv); Los Angeles County Department of Mental Health, Los Angeles (Nowlin-Finch); Veterans Maryland Healthcare System, Baltimore (Goldberg).

Notes

Send correspondence to Dr. Young ([email protected]).

Competing Interests

Dr. Young has received consulting fees from Relias Learning and a research contract from Ameritox. The other authors report no financial relationships with commercial interests.

Funding Information

This research was supported by the Health Services Research and Development Service (IIR 09–083) and the Desert Pacific Mental Illness Research, Education and Clinical Center (MIRECC), Veterans Health Administration, U.S. Department of Veterans Affairs and by the National Institute of Mental Health (R34MH090207). The views expressed in this report are those of the authors and do not necessarily reflect the position or policy of any of the authors’ employers.

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