On the HORYZON: Moderated online social therapy for long-term recovery in first episode psychosis

Abstract

Background

Early intervention services have demonstrated improved outcomes in first episode psychosis (FEP); however, recent evidence shows that treatment benefits may not be sustainable over time. These findings have resulted in repeated recommendations for the implementation of longer term treatment programs. An Internet-based intervention specifically designed for young people with psychosis may provide a cost-effective alternative to prevent loss of treatment benefits from early intervention.

Methods

Our multi-disciplinary team has developed a highly novel online intervention (HORYZONS) in regular consultation with stakeholders within a specialist early psychosis program. HORYZONS integrates: i) peer-to-peer social networking, ii) individually tailored interactive psychosocial interventions, and iii) expert interdisciplinary and peer-moderation in a coherent platform designed to improve long-term outcomes in FEP. The acceptability, safety and initial clinical benefits of HORYZONS were examined through a 1-month pilot study with 20 participants with FEP.

Results

There were no dropouts during the pilot study. Seventy per cent of participants utilised the system for at least 3 weeks, 95% used the social networking features, and 60% completed at least 3 therapy modules. System usage was high during the study. There were no incidents and the majority of participants reported feeling safe, empowered and more socially connected using HORYZONS. Analysis revealed a significant reduction in depressive symptoms at follow-up.

Conclusions

Our results indicate that HORYZONS is feasible, engaging and safe and may augment social connectedness and empowerment in FEP. These findings have significant implications for the enhancement of specialist FEP services. The potential of HORYZONS to improve long-term recovery is worthy of further investigation.

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.