On the HORYZON: Moderated online social therapy for long-term recovery in first episode psychosis
Introduction
Over the preceding two decades, early intervention for psychosis has emerged as a major international psychiatric reform (McGorry and Yung, 2003). The transformation of psychiatric care has led to the proliferation of specialist first episode psychosis (FEP) services in Australia, Europe, North America and Asia (McGorry et al., 2008). Early psychosis services seek to provide timely entry into treatment and support young people in achieving both symptomatic remission and full functional recovery (McGorry et al., 1996). They adopt a youth-friendly and recovery-focussed model in order to empower young people to become more involved in their own treatment decisions and prevent the development of self-stigma, comorbid symptomatology and functional and social disability (McGorry et al., 2008). Controlled and quasi-experimental research has demonstrated that specialist FEP services improve psychotic symptoms (Petersen et al., 2005), reduce relapse rates (Craig et al., 2004, Petersen et al., 2005, Alvarez-Jimenez et al., 2011) and comorbid substance misuse (Petersen et al., 2005), and foster functional recovery (Melle et al., 2004), engagement with services (Craig et al., 2004) and patient satisfaction (Petersen et al., 2005), at least during the first 2 years of treatment.
However, the maintenance of treatment effects poses a major challenge to achieving the aims of early intervention (Singh, 2010, Gleeson et al., 2011). Patients with FEP are responsive to acute-phase treatments, but relapse rates are high (Alvarez-Jimenez et al., 2012a). Our group has developed effective cognitive-based interventions for relapse prevention in FEP (Gleeson et al., 2009), but treatment benefits were lost over time suggesting the interventions needed to be maintained over the longer term (Gleeson et al., 2011). More generally, specialist FEP services typically have treatment resources for only 18 months to 2 years, and recent reports suggest that the benefits of early intervention seen at the end of 2 years may not persist at 5 years after patients have been receiving generic follow-up (Bertelsen et al., 2008, Gafoor et al., 2010). These findings have triggered widespread calls for studies assessing the effects of longer term treatment programs (Bertelsen et al., 2008, Friis, 2010, Singh, 2010).
The positive effects of specialist FEP services are likely to persist when patients continue to receive specialised treatment (Linszen et al., 2001, Norman et al., 2011). This view is supported by the evidence that the first 5 years after psychosis onset constitutes a critical period determining longer term outcomes (Crumlish et al., 2009, Norman et al., 2011). Indeed, the period of risk for relapse extends well beyond the timeframe of specialist FEP services (Alvarez-Jimenez et al., 2012a). Furthermore, the termination of the specialised intervention and the transfer of care bring about feelings of loss for the patients (Bertelsen et al., 2008) and significantly derail engagement with treatment services (Singh, 2010), a pivotal element of early intervention programmes.
In this context, there is a clear need to fully realise the aims of early intervention by extending its effectiveness through innovative approaches (Kreyenbuhl et al., 2009, Singh, 2010). A stepped down level of care which bridges the gap between specialised intervention and standard treatment could provide a cost-effective alternative to prevent loss of treatment benefits and reduce the risk for disengagement from mental health services over the longer term (Norman and Malla, 2001). Internet-based interventions have the potential to realise this goal through providing cost-effective, non-stigmatising, constantly available support to young people suffering from psychosis.
This article aims to: i) provide a rationale for Internet-based interventions for psychosis and their potential to improve long-term recovery in FEP; ii) describe the development of a world-first online psychosocial intervention (HORYZONS) designed to maintain the benefits of early intervention beyond discharge from specialist FEP services; and iii) examine the feasibility, acceptability, safety and potential clinical benefits of HORYZONS in FEP patients through a pilot study.
Section snippets
Are online interventions for first episode psychosis feasible?
The Internet and mobile technologies are developing at a phenomenal rate and hold great promise for influencing and even transforming treatment delivery in psychosis (Ben-Zeev, 2012). These technologies can be particularly useful for young people with FEP as individuals under 25 are by far the greatest users of Internet resources (Lloyd and Bill, 2004). Indeed, 95% of young Australians use the Internet daily (Ewing et al., 2008) and 96% of people aged 16–24 in the UK have used the Internet,
Development of the MOST model and the HORYZONS system
In line with the aforementioned recommendations, we have developed a new conceptual model of on-line behavioural interventions entitled “Moderated On-line Social Therapy” (MOST). The MOST model integrates: i) peer-to-peer on-line social networking; ii) individually tailored interactive psychosocial interventions; and (iii) involvement of expert mental health and peer moderators to ensure the safety of the intervention. The elements of the MOST model have been applied to a world-first on-line
The HORYZONS pilot study
The purpose of the pilot study was to conduct an initial evaluation of HORYZONS regarding its feasibility, acceptability, safety and potential clinical utility for FEP patients. We hypothesised that HORYZONS would be: 1) feasible and favourably received; 2) regularly used; 3) safe; and 4) viewed as a useful tool for long-term recovery and social connectedness.
Discussion
To the best of our knowledge, this is the first study to develop and test an online intervention specifically designed for FEP patients, and is possibly a world-first intervention using the MOST model. HORYZONS has been developed by a multidisciplinary team of experts in constant consultation with stakeholders. It uniquely integrates peer-to-peer online social networking, evidence-based interventions and professional and peer support in a coherent, innovative platform designed to provide
Role of funding Source
This study was supported by generous funding from the Telstra Foundation, the Helen MacPherson Smith Trust, the University of Melbourne, the Telematics Trust, The Institute for a Broadband-Enabled Society (IBES), and the Colonial Foundation. The sponsors did not participate in the design or conduct of this study; in the collection, management, analysis, or interpretation of data; in the writing of the manuscript; or in the preparation, review, approval, or decision to submit this manuscript for
Contributors
MA-J and JF-G supervised the study and wrote the first draft of the manuscript. S-B, R-L, G-W, G-C, S-V and M-L significantly contributed to the development and evaluation of HORYZONS. E-K and PD-M contributed to the design of the study and critically revised the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
The authors report no additional financial or other affiliation relevant to the subject of this article.
The following are the supplementary data related to this article.
Acknowledgements
The authors wish to thank Christopher Miles, Kathryn Junor and Sylvia Collinety for their contribution to the development of HORYZONS, and the study participants for their valuable contributions to this research.
References (74)
- et al.
Internet-based interventions for psychosis: a sneak-peek into the future
Psychiatr. Clin. North Am.
(2012) - et al.
Cognitive dimensions in first-episode schizophrenia spectrum disorders
J. Psychiatr. Res.
(2007) - et al.
The cognitive–behavioural treatment of low self-esteem in psychotic patients: a pilot study
Behav. Res. Ther.
(2003) - et al.
Early intervention and a five year follow up in young adults with a short duration of untreated psychosis: ethical implications
Schizophr. Res.
(2001) - et al.
Social support and three-year symptom and admission outcomes for first episode psychosis
Schizophr. Res.
(2005) - et al.
Symptom and functional outcomes for a 5 year early intervention program for psychoses
Schizophr. Res.
(2011) - et al.
ITAREPS: information technology aided relapse prevention programme in schizophrenia
Schizophr. Res.
(2008) - et al.
Assessing depression in schizophrenia — the Calgary Depression Scale
Br. J. Psychiatry
(1993) - et al.
Predictors of adherence to cognitive–behavioural therapy in first-episode psychosis
Can. J. Psychiatry
(2009)
Preventing the second episode: a systematic review and meta-analysis of psychosocial and pharmacological trials in first-episode psychosis
Schizophr. Bull.
Risk factors for relapse following treatment for first episode psychosis: a systematic review and meta-analysis of longitudinal studies
Schizophr. Res.
Diagnostic and Statistical Manual of Mental Disorders
Old Wine in New Bottles or Novel Challenges? A Critical Analysis of Empirical Studies of User Experience
An inventory for measuring clinical anxiety: psychometric properties
J. Consult. Clin. Psychol.
Mobile technologies in the study, assessment, and treatment of schizophrenia
Schizophr. Bull.
Five-year follow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial
Arch. Gen. Psychiatry
Predicting relapse in schizophrenia: the development and implementation of an early signs monitoring system using patients and families as observers, a preliminary investigation
Psychol. Med.
A comparison of changes in anxiety and depression symptoms of spontaneous users and trial participants of a cognitive behavior therapy website
J. Med. Internet Res.
Online randomized controlled trial of brief and full cognitive behaviour therapy for depression
Psychol. Med.
Overcoming Depression on the Internet (ODIN) (2): a randomized trial of a self-help depression skills program with reminders
J. Med. Internet Res.
Impact of consumer-operated services on empowerment and recovery of people with psychiatric disabilities
Psychiatr. Serv.
The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis
BMJ
Beyond the critical period: longitudinal study of 8-year outcome in first-episode non-affective psychosis
Br. J. Psychiatry
Finding Flow: the Psychology of Engagement with Everyday Life
Peer support among adults with serious mental illness: a report from the field
Schizophr. Bull.
Mobile interventions for severe mental illness: design and preliminary data from three approaches
J. Nerv. Ment. Dis.
Randomised controlled trial of a cannabis-focused intervention for young people with first-episode psychosis
Acta Psychiatr. Scand.
CCI Digital Futures Report: the Internet in Australia. ARC Centre of Excellence for Creative Industries and Innovation Institute for Social Research
The law of attrition
J. Med. Internet Res.
Structured clinical interview for DSM-IV Axis I Disorders—Patient Version (SCID-I/P)
Early specialised treatment for first-episode psychosis: does it make a difference?
Br. J. Psychiatry
Effect of early intervention on 5-year outcome in non-affective psychosis
Br. J. Psychiatry
A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients
J. Clin. Psychiatry
A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients: outcome at 30-month follow-up
Schizophr. Bull.
Monitoring youth depression risk in Web 2.0. Vine
J. Inf. Knowl. Manag. Syst.
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