Search

Conventional mental health treatments do not meet the needs of all who seek help: some consult informal and alternative providers. Researching the use and perceived benefits of these non-conventional sources of help may contribute to understanding help-seeking behavior and inform mental health policy. We explored the experiences of people consulting psychics (a type of alternative provider) for mental health needs, through comparisons with experiences of people consulting conventional and informal providers. An online survey sought feedback on help seeking for stress or emotional problems from 734 adults who had consulted a psychologist or counsellor; doctor or psychiatrist who prescribed medication; friend or family member; or psychic or similar alternative provider. Analyses included descriptive and inferential statistics and content analysis of textual responses. Problems were commonly described in symptom or disorder terminology with considerable overlap across groups. Content analysis of reasons for choice of helper identified four main categories—functional, reasoned, emotional, and passive—which differed significantly across groups (Cramer’s V = 0.26), with consulting psychics predominantly a reasoned choice. Ratings of overall effectiveness of help by those consulting psychics were greater than for the three other groups (d = 0.31 to 0.42), with very few adverse outcomes in any group. Help seeking for stress or emotional problems includes consultations with psychics or similar alternative providers, with self-reported outcomes better than for conventional providers. Further research is warranted to establish whether psychic consultations may serve a useful public health function.

Psychosocial, evidence-based interventions (EBI) may support personal recovery from psychosis; however, little is known about their implementation.: This paper describes the adaptation, implement...

Digital technologies enable the dissemination of multimedia resources to support adults with serious mental illness in their self-management and personal recovery. However, delivery needs to accommodate engagement and accessibility challenges.We examined how a digital resource, designed for mental health workers and consumers to use together in session, would be used in routine practice.Thirty consumers and their workers participated. The web-based resource, Self-Management And Recovery Technology (SMART), was available to use within and between sessions, for a 6-month period. Workers initiated in-session use where relevant. Feasibility was explored via uptake and usage data; and acceptability and impact via questionnaires. A pre-post design assessed recovery outcomes for consumers and relationship outcomes for consumers and workers.In participating mental health practitioner-consumer dyads, consumers gave strong acceptability ratings, and reported improved working relationships. However, the resource was typically used in one-third or fewer appointments, with consumers expressing a desire for greater in-session use. Improvements in self-rated personal recovery were not observed, possibly contributed to by low usage.In-session use was found helpful by consumers but may be constrained by other demands in mental health care delivery: collaborative use may require dedicated staff time or more formal implementation.

Objectives: To study the end-user experiences of participants randomised to receive a blended digital intervention for relapse prevention in schizophrenia in the context of a cluster randomised controlled feasibility trial.Design: A qualitative interview design with thematic analysis was used.Method: A subsample of EMPOWER participants comprising 16 patients, 5 mental health staff and one carer were interviewed one-on-one.Results: Two overarching themes were constructed that were relevant for understanding end-user experiences within the EMPOWER trial: Affordances and Change Processes. Affordances described the processes underpinning how and why participants interacted with or avoided the various components of the intervention. Affordances spanned all EMPOWER components, including self-monitoring, peer support workers, clinical triaging, self-management messages and diary function. The affordances were Access to Social Connection, Access to Digital, Access to Mental Health Support, the Ability to Gauge Mental Health and Access to Mental Health Information. The affordances framework helped explain the multitude of engagement trajectories featured within the qualitative interviews. If participants sustained usage, affordances acted as a springboard for change processes, including increased self-confidence that patients could self-manage, noticing patterns and changes, and using EMPOWER as a conversation starter.Conclusions: The implementation process of EMPOWER was emergent and was best described by the intervention offering a range of affordances which could act as implementation barriers or facilitators depending on individual needs and wants. Affordances may present a sound theoretical framework for explaining end-user experiences.

Recovery-oriented perspectives have become accepted worldwide as an alternative to the biomedical approach to conceptualizing and managing severe mental health problems. It has been proposed that one advantage of this is to support self-efficacy amongst people with a lived experience of psychosis, especially when recovery messages are presented by lived experience peers. The aim of the present study was to investigate the proposed psychological benefits of the recovery paradigm, by testing for possible differential impacts of recovery versus biomedical messages on self-efficacy beliefs and positive emotional state amongst people with experience of psychosis. It was hypothesized that (1) recovery-oriented messages, when presented by lived experience peers, would generate improvements in self-efficacy and positive emotions relative to biomedical messages presented by a professional and (2) recovery-oriented messages delivered by a professional would generate improvements in self-efficacy and positive emotions relative to biomedical messages delivered by a professional. We also explored whether recovery-oriented messages were more impactful when delivered by a lived experience peer versus a professional.Experimental design with three within-subject video-based conditions.Fifty-three participants with lived experience of psychosis viewed three videos: (i) people with lived experience sharing their experiences of recovery; (ii) mental health professionals presenting traditional biomedical conceptualizations of psychosis; and (iii) mental health professionals presenting recovery perspectives. Participants provided baseline clinical and demographic information, and post-viewing ratings of experienced changes in self-efficacy and emotional state.Hypothesis 1 was supported: both self-efficacy and positive emotions were significantly increased by a video of peers sharing personal recovery stories relative to professionals presenting biomedical messages. Hypothesis 2 was partially supported: when comparing videos of recovery versus biomedical messages delivered by professionals, significant relative benefits were found for positive emotions, but not self-efficacy.This experimental investigation generated a pattern of findings broadly supportive of the assumed psychological benefits of the recovery paradigm for people with lived experiences of psychosis. Findings must be interpreted with caution given the limitations of the present design, but encourage further experimental research to directly test the interpersonal impacts of the recovery paradigm.

Background There is an emerging international literature demonstrating clinical and cost-effectiveness of sub-acute residential mental health services. To date, however, there is limited information on the profile of consumers accessing these models of care. This study aimed to understand the profile of the population served by adult sub-acute residential mental health services in Victoria, Australia (known as Prevention and Recovery Care; PARC) and to compare PARC service consumers with consumers admitted to psychiatric inpatient units within public hospitals. Method Using 5 years (2012–2016) of a state-wide database of routinely collected individual level mental health service data, we describe the socio-demographic and clinical profile of PARC service consumers compared to consumers of psychiatric inpatient units including for primary diagnosis and illness severity. Using admissions as the unit of analysis, we identify the characteristics that distinguish PARC service admissions from psychiatric inpatient admissions. We also examine and compare length of stay for the different admission types. Results We analysed 78,264 admissions representing 34,906 individuals. The profile of PARC service consumers differed from those admitted to inpatient units including for sex, age, diagnosis and illness severity. The odds of an admission being to a PARC service was associated with several socio-demographic and clinical characteristics. Being male or in the youngest age grouping ( Conclusions Our findings suggest PARC services may serve an overlapping but distinguishably different consumer group than inpatient psychiatric units. Future research on sub-acute mental health services should be cognizant of these consumer differences, particularly when assessing the long-term effectiveness of this service option.

Neurocognitive impairments are well established in both ultra-high risk (UHR) for psychosis and major depressive disorder (MDD). Despite this understanding, investigation of neurocognitive deficits in UHR individuals with MDD and its association with MDD within this population, has been scarce. Hence, this study aimed to examine any differences in neurocognition at baseline between those with MDD at baseline and those with no history of MDD, as well as determine whether neurocognitive variables are significantly associated with meeting criteria for MDD at follow-up, while controlling for relevant clinical variables, within a UHR cohort. Data analysis was conducted on 207 participants whose baseline neurocognition was assessed using Brief Assessment of Cognition for Schizophrenia, as part of a trial of omega-3 fatty acids (NEURAPRO) for UHR individuals. While baseline MDD was the strongest predictor, poorer verbal memory and higher verbal fluency were significantly associated with MDD at 12 months (p =.04 and 0.026, respectively). Further, higher processing speed was significantly associated with MDD at medium-term follow-up (p =.047). These findings outline that neurocognitive skills were independently associated with meeting criteria for MDD at follow-up within UHR individuals, with novel findings of better verbal fluency and processing speed being linked to MDD outcomes. Hence, neurocognitive performance should be considered as a marker of risk for MDD outcomes and a target for management of MDD in UHR.

Background Voice-hearing experiences can be distressing and impairing, and existing psychological treatments show modest effectiveness. Ecological momentary assessment and intervention (EMA/I) are two promising approaches which may be used as digital tools to support and enhance existing psychological therapies. The aim of this study was to investigate the potential clinical utility of smartphone-based EMA/I in a blended, coping focused therapy for voice-hearing experiences. Method: This pilot RCT focused on feasibility, acceptability and preliminary estimations of efficacy. Thirty-four participants with persisting and distressing voices were randomised to receive the four-session intervention along-side treatment-as-usual (TAU) or TAU-only. Results: Findings supported the feasibility and acceptability of the approach, with good engagement and satisfaction rates, and clinical outcomes showed the intervention holds promise for improving coping, overall severity of voices and to some degree their negative impact. Conclusion: This is the first examination of the use of EMA/I in a blended therapy for psychotic experiences, with findings suggesting these technologies show promise as clinical tools.

Background. For people with persisting psychotic disorders, personal recovery has become an important target of mental health services worldwide. Strongly influenced by mental health service consumer perspectives, personal recovery refers to being able to live a satisfying and contributing life irrespective of ongoing symptoms and disability. Contact with peers with shared lived experience is often cited as facilitative of recovery. We aimed to develop and pilot a novel recovery-based digitally-supported intervention for people with a psychotic illness. Methods. We developed a website to be used on a tablet computer by mental health workers to structure therapeutic discussions about personal recovery. Central to the site was a series of video interviews of people with lived experience of psychosis discussing how they had navigated issues within their own recovery based on the Connectedness—Hope—Identity—Meaning—Empowerment (CHIME) model of recovery. We examined the feasibility and acceptability of an 8-session low intensity intervention using this site in 10 participants with persisting psychotic disorders, and conducted a proof-of-concept analysis of outcomes. Results. All 10 participants completed the full course of sessions and it was possible to integrate use of the website into nearly all sessions. Participant feedback confirmed that use of the website was a feasible and acceptable way of working. All participants stated that they would recommend the intervention to others. Post-intervention, personal recovery measured by the Questionnaire for the Process of Recovery had improved by an average standardised effect of d = 0.46, 95% CI [.07, .84], and 8 or the 10 participants reported that their mental health had improved since taking part in the intervention. Conclusions. In-session use of digital resources featuring peer accounts of recovery is feasible and acceptable, and shows promising outcomes. A randomised controlled trial is the next step in evaluating the efficacy of this low intensity intervention when delivered in conjunction with routine mental health care.

Background: \ud Early warning signs monitoring by service users with schizophrenia has shown promise in preventing relapse but the quality of evidence is low. We aimed to establish the feasibility of undertaking a definitive randomised controlled trial to determine the effectiveness of a blended digital intervention for relapse prevention in schizophrenia.\ud \ud Methods: \ud This multicentre, feasibility, cluster randomised controlled trial aimed to compare Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery (EMPOWER) with treatment as usual in community mental health services (CMHS) in Glasgow and Melbourne. CMHS were the unit of randomisation, selected on the basis of those that probably had five or more care coordinators willing to participate. Participants were eligible if they were older than 16 years, had a schizophrenia or related diagnosis confirmed via case records, were able to provide informed consent, had contact with CMHS, and had had a relapse within the previous 2 years. Participants were randomised within stratified clusters to EMPOWER or to continue their usual approach to care. EMPOWER blended a smartphone for active monitoring of early warning signs with peer support to promote self-management and clinical triage to promote access to relapse prevention. Main outcomes were feasibility, acceptability, usability, and safety, which was assessed through face-to-face interviews. App usage was assessed via the smartphone and self-report. Primary end point was 12 months. Participants, research assistants and other team members involved in delivering the intervention were not masked to treatment conditions. Assessment of relapse was done by an independent adjudication panel masked to randomisation group. The study is registered at ISRCTN (99559262).\ud \ud Findings: \ud We identified and randomised eight CMHS (six in Glasgow and two in Melbourne) comprising 47 care coordinators. We recruited 86 service users between Jan 19 and Aug 8, 2018; 73 were randomised (42 [58%] to EMPOWER and 31 [42%] to treatment as usual). There were 37 (51%) men and 36 (49%) women. At 12 months, main outcomes were collected for 32 (76%) of service users in the EMPOWER group and 30 (97%) of service users in the treatment as usual group. Of those randomised to EMPOWER, 30 (71%) met our a priori criterion of more than 33% adherence to daily monitoring that assumed feasibility. Median time to discontinuation of these participants was 31·5 weeks (SD 14·5). There were 29 adverse events in the EMPOWER group and 25 adverse events in the treatment as usual group. There were 13 app-related adverse events, affecting 11 people, one of which was serious. Fear of relapse was lower in the EMPOWER group than in the treatment as usual group at 12 months (mean difference –7·53 (95% CI –14·45 to 0·60; Cohen's d –0·53).\ud \ud Interpretation: \ud A trial of digital technology to monitor early warning signs blended with peer support and clinical triage to detect and prevent relapse appears to be feasible, safe, and acceptable. A further main trial is merited.\ud \ud Funding: \ud UK National Institute for Health Research Health Technology Assessment programme and the Australian National Health and Medical Research Council.

Background Little is known about factors associated with engagement with online interventions for psychosis. This review aimed to synthesise existing data from relevant literature to develop a working model of potential variables that may impact on engagement with online interventions for psychosis. Methods Online databases were searched for studies relevant to predictors of engagement with online interventions for psychosis; predictors of Internet use amongst individuals with psychosis; and predictors of engagement with traditional psychosocial treatments for psychosis. Data were synthesised into a conceptual model highlighting factors relevant to engagement with online interventions for psychosis. Results Sixty-one studies were identified. Factors relevant to engagement related directly to the impact of psychosis, response to psychosis, integration of technology into daily lives and intervention aspects. Conclusion While several candidate predictors were identified, there is minimal research specifically investigated predictors of engagement with online interventions for psychosis. Further investigation examining both individual- and intervention-related factors is required to inform effective design and dissemination of online interventions for psychosis., Highlights • Engagement may be associated with illness factors such as the impact of psychotic symptoms. • Engagement may be associated with one's exposure to technology including computer literacy. • Engagement may be associated with individuals' response to psychosis including recovery style and internalised stigma. • Intervention design factors such as adjunct support may assist to overcome challenges with engagement.

BackgroundFamily education programs (FEPs) target caregiving-related psychological distress for carers of relatives/friends diagnosed with serious mental health conditions. While FEPs are efficacious in reducing distress, the mechanisms are not fully known. Peer group support and greater mental health knowledge are proposed to reduce carers' psychological distress by reducing stigmatising attitudes and self-blame, and strengthening carers' relationship with their relative.MethodsAdult carers (n = 1016) who participated in Wellways Australia's FEP from 2009 to 2016 completed self-report questionnaires at the core program's start and end, during the consolidation period, and at a 6-month follow-up. Those who enrolled early completed questionnaires prior to a wait-list period. We used linear mixed-effects modelling to assess the program's effectiveness using a naturalistic wait-list control longitudinal design, and multivariate latent growth modelling to test a theory-based process change model.ResultsWhile there was no significant change over the wait-list period, psychological distress, self-blame and stigmatising attitudes significantly decreased, and communication and relationship quality/feelings increased from the core program's start to its end. Changes were maintained throughout the consolidation period and follow-up. Peer group support significantly predicted the declining trajectory of distress. Peer group support and greater knowledge significantly predicted declining levels of self-blame and stigmatising attitudes, and increasing levels of communication.ConclusionsThis is the first study to quantitatively validate the mechanisms underlying the effect of FEPs on carers' psychological distress. Peer group support is key in modifying carers' appraisals of their friend/relatives' condition. Continued implementation of FEPs within mental health service systems is warranted.

Background: Fear of relapse is an independent risk factor for future relapse events indicating its importance in clinical management and early warning signs-based relapse prevention monitoring.Methods: 25 participants who were taking part in a clinical trial of relapse prevention in schizophrenia responded to daily ecological momentary assessment prompts assessing common early warning signs of relapse and self-reported positive experiences like feeling supported by others. We conducted multilevel vector auto-regression using common symptoms assessed in early warning signs monitoring relapse prevention while controlling for positive self-reported experiences like feeling supported by others to estimate three networks (to explore concurrent, temporal and mean levels across the whole time period).Results: Reporting fear of relapse was positively associated (within the same cross-sectional time window) with hearing voices, alongside anxiety, negative affect and sleep change. Fear of relapse appeared to predict anxiety and negative affect on the next consecutive day. Experiencing fear of relapse on one day meant being more likely to also experience fear of relapse again at the next consecutive time point. However, none of the common early warning signs predicted fear of relapse within the temporal window and all observed relationships were small. Discussion: Early warning signs themselves appear poor predictors of experiencing fear of relapse but because fear of relapse predicts later anxiety and negative affect (even to a small degree) it may be a valuable intervention target within the daily life of people diagnosed with schizophrenia.

Objective: In Victoria, Prevention and Recovery Care Services have been established to provide a partial alternative to inpatient admissions through short-term residential mental health care in the community. This study set out to determine whether Prevention and Recovery Care Services are achieving their objectives in relation to reducing service use and costs, fostering least restrictive care and leading to positive clinical outcomes. Methods: We matched 621 consumers whose index admission in 2014 was to a Prevention and Recovery Care (‘PARCS consumers’) with 621 similar consumers whose index admission in the same year was to an acute inpatient unit and who had no Prevention and Recovery Care stays for the study period (‘inpatient-only consumers’). We used routinely collected data to compare them on a range of outcomes. Results: Prevention and Recovery Care Services consumers made less subsequent use of acute inpatient services and, on balance, incurred costs that were similar to or lower than inpatient-only consumers. They were also less likely to spend time on an involuntary treatment order following their index admission. Prevention and Recovery Care Services consumers also experienced positive clinical outcomes over the course of their index admission, but the magnitude of this improvement was not as great as for inpatient-only consumers. This type of clinical improvement is important for Prevention and Recovery Care Services, but they may place greater emphasis on personal recovery as an outcome. Conclusion: Prevention and Recovery Care Services can provide an alternative, less restrictive care option for eligible consumers who might otherwise be admitted to an acute inpatient unit and do so at no greater cost.

BACKGROUND e–Mental health resources are increasingly available for people who experience severe mental illness, including those who are users of community mental health services. However, the potential for service users (SUs) living with severe mental illness to use e–mental health resources together with their community mental health workers (MHWs) has received little attention. OBJECTIVE This study aims to identify how jointly using an interactive website called Self-Management And Recovery Technology (SMART) in a community mental health context influenced therapeutic processes and interactions between SUs and MHWs from their perspective. METHODS We conducted a qualitative study using a constructivist grounded theory methodology. Data were collected through individual semistructured interviews with 37 SUs and 15 MHWs who used the SMART website together for 2 to 6 months. Data analysis involved iterative phases of coding, constant comparison, memo writing, theoretical sampling, and consultation with stakeholders to support the study’s credibility. RESULTS A substantive grounded theory, discovering ways to keep life on track, was developed, which portrays a shared discovery process arising from the SU-worker-SMART website interactions. The discovery process included choosing to use the website, revealing SUs’ experiences, exploring these experiences, and gaining new perspectives on how SUs did and could keep their lives on track. SUs and MHWs perceived that their three-way interactions were enjoyable, beneficial, and recovery focused when using the website together. They experienced the shared discovery process as relationship building—their interactions when using the website together were more engaging and equal. CONCLUSIONS Jointly using an e–mental health resource elicited recovery-oriented interactions and processes between SUs and MHWs that strengthened their therapeutic relationship in real-world community mental health services. Further work to develop and integrate this novel use of e–mental health in community mental health practice is warranted.

BACKGROUND Recruitment processes for clinical trials of digital interventions for psychosis are seldom described in detail in the literature. Although trial staff have expertise in describing barriers to and facilitators of recruitment, a specific focus on understanding recruitment from the point of view of trial staff is rare, and because trial staff are responsible for meeting recruitment targets, a lack of research on their point of view is a key limitation. OBJECTIVE The primary aim of this study was to understand recruitment from the point of view of trial staff and discover what they consider important. METHODS We applied pluralistic ethnographic methods, including analysis of trial documents, observation, and focus groups, and explored the recruitment processes of the EMPOWER (Early Signs Monitoring to Prevent Relapse in Psychosis and Promote Well-being, Engagement, and Recovery) feasibility trial, which is a digital app–based intervention for people diagnosed with schizophrenia. RESULTS Recruitment barriers were categorized into 2 main themes: service characteristics (lack of time available for mental health staff to support recruitment, staff turnover, patient turnover [within Australia only], management styles of community mental health teams, and physical environment) and clinician expectations (filtering effects and resistance to research participation). Trial staff negotiated these barriers through strategies such as emotional labor (trial staff managing feelings and expressions to successfully recruit participants) and trying to build relationships with clinical staff working within community mental health teams. CONCLUSIONS Researchers in clinical trials for digital psychosis interventions face numerous recruitment barriers and do their best to work flexibly and to negotiate these barriers and meet recruitment targets. The recruitment process appeared to be enhanced by trial staff supporting each other throughout the recruitment stage of the trial.

BACKGROUND Recruitment processes for clinical trials of digital interventions for psychosis are seldom described in detail within the literature. While trial staff have expertise in describing barriers and facilitators to recruitment a specific focus on understanding recruitment from the point of view of trial staff is rare. OBJECTIVE The primary aim of this study was to understand recruitment from the point of view of trial staff and discover what they considered to be important. METHODS We applied pluralistic ethnographic methods including analysis of trial documents, observation and focus groups explored the recruitment processes of the EMPOWER feasibility trial (ISRCTN: 99559262) RESULTS Recruitment barriers fell into two main themes; service characteristics (lack of time available to mental health staff to support recruitment, staff turnover, patient turnover (within Australia only), management styles of community mental health teams, physical environment) and clinician expectations (filtering effects and resistance to research participation). Trial staff negotiated these barriers through strategies such as emotional labour (trial staff managing feelings and expressions in order to successfully recruit participants) and trying to build relationships with clinical staff working within community mental health teams. CONCLUSIONS Researchers in clinical trials for digital psychosis interventions face numerous recruitment barriers and do their best to work flexibly negotiate these barriers and meet recruitment targets. The recruitment process appeared to be enhanced by trial staff supporting each other throughout the recruitment stage of the trial. CLINICALTRIAL ISRCTN: 99559262 INTERNATIONAL REGISTERED REPORT RR2-10.2196/15634

There is a growing recognition that psychiatric symptoms have the potential to causally interact with one another. Particularly in the earliest stages of psychopathology dynamic interactions between symptoms could contribute heterogeneous and cross-diagnostic clinical evolutions. Current clinical approaches attempt to merge clinical manifestations that co-occur across subjects and could therefore significantly hinder our understanding of clinical pathways connecting individual symptoms. Network approaches have the potential to shed light on the complex dynamics of early psychopathology. In the present manuscript we attempt to address 2 main limitations that have in our opinion hindered the application of network approaches in the clinical setting. The first limitation is that network analyses have mostly been applied to cross-sectional data, yielding results that often lack the intuitive interpretability of simpler categorical or dimensional approaches. Here we propose an approach based on multi-layer network analysis that offers an intuitive low-dimensional characterization of longitudinal pathways involved in the evolution of psychopathology, while conserving high-dimensional information on the role of specific symptoms. The second limitation is that network analyses typically characterize symptom connectivity at the level of a population, whereas clinical practice deals with symptom severity at the level of the individual. Here we propose an approach based on graph signal processing that exploits knowledge of network interactions between symptoms to predict longitudinal clinical evolution at the level of the individual. We test our approaches in two independent samples of individuals with genetic and clinical vulnerability for developing psychosis.

Background: Recruitment processes for clinical trials of digital interventions for psychosis are seldom described in detail within the literature. While trial staff have expertise in describing barriers and facilitators to recruitment a specific focus on understanding recruitment from the point of view of trial staff is rare.Methods: We applied pluralistic ethnographic methods including analysis of trial documents, observation and focus groups explored the recruitment processes of the EMPOWER feasibility trial (ISRCTN: 99559262).Results: Recruitment barriers fell into two main themes; service characteristics (lack of time available to mental health staff to support recruitment, staff turnover, patient turnover (within Australia only), management styles of community mental health teams, physical environment) and clinician expectations (filtering effects and resistance to research participation). Trial staff negotiated these barriers through strategies such as emotional labour (trial staff managing feelings and expressions in order to successfully recruit participants) and trying to build relationships with clinical staff working within community mental health teams.Conclusions: Researchers in clinical trials for digital psychosis interventions face numerous recruitment barriers and do their best to work flexibly negotiate these barriers and meet recruitment targets. The recruitment process appeared to be enhanced by trial staff supporting each other throughout the recruitment stage of the trial.Trial Registration: (ISRCTN: 99559262 registered 21/12/2015)

BackgroundRelapse in schizophrenia is a major cause of distress and disability and is predicted by changes in symptoms such as anxiety, depression, and suspiciousness (early warning signs [EWSs]). These can be used as the basis for timely interventions to prevent relapse. However, there is considerable uncertainty regarding the implementation of EWS interventions.ObjectiveThis study was designed to establish the feasibility of conducting a definitive cluster randomized controlled trial comparing Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery (EMPOWER) against treatment as usual (TAU). Our primary outcomes are establishing parameters of feasibility, acceptability, usability, safety, and outcome signals of a digital health intervention as an adjunct to usual care that is deliverable in the UK National Health Service and Australian community mental health service (CMHS) settings. We will assess the feasibility of candidate primary outcomes, candidate secondary outcomes, and candidate mechanisms for a definitive trial.MethodsWe will randomize CMHSs to EMPOWER or TAU. We aim to recruit up to 120 service user participants from 8 CMHSs and follow them for 12 months. Eligible service users will (1) be aged 16 years and above, (2) be in contact with local CMHSs, (3) have either been admitted to a psychiatric inpatient service or received crisis intervention at least once in the previous 2 years for a relapse, and (4) have an International Classification of Diseases-10 diagnosis of a schizophrenia-related disorder. Service users will also be invited to nominate a carer to participate. We will identify the feasibility of the main trial in terms of recruitment and retention to the study and the acceptability, usability, safety, and outcome signals of the EMPOWER intervention. EMPOWER is a mobile phone app that enables the monitoring of well-being and possible EWSs of relapse on a daily basis. An algorithm calculates changes in well-being based on participants’ own baseline to enable tailoring of well-being messaging and clinical triage of possible EWSs. Use of the app is blended with ongoing peer support.ResultsRecruitment to the trial began September 2018, and follow-up of participants was completed in July 2019. Data collection is continuing. The database was locked in July 2019, followed by analysis and disclosing of group allocation.ConclusionsThe knowledge gained from the study will inform the design of a definitive trial including finalizing the delivery of our digital health intervention, sample size estimation, methods to ensure successful identification, consent, randomization, and follow-up of participants, and the primary and secondary outcomes. The trial will also inform the final health economic model to be applied in the main trial.Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN): 99559262; http://isrctn.com/ISRCTN99559262International Registered Report Identifier (IRRID)DERR1-10.2196/15058

OBJECTIVE: Increased employment duration has been associated with change in performance on specific neurocognitive domains in populations with schizophrenia, but not in first-episode psychosis. The aim of this exploratory study was to examine whether employment duration over 18 months is associated with neurocognitive outcomes over 18 months among individuals with first-episode psychosis. METHOD: Eighty-eight young people with first-episode psychosis completed a neurocognitive battery at baseline and 18 months. Setwise (hierarchical) multivariate linear regressions were used to examine predictors of change in neurocognitive performance over 18 months. Total hours employed over 18 months were entered after accounting for age, gender, premorbid IQ, and negative symptom change scores. RESULTS: Total hours employed was significantly associated with change in Symbol Digit Modalities Test raw score (p = .020), Letter-Number Sequencing scaled score (p = .016), Digit Span total scaled score (p = .047) and Rey Complex Figure Test delayed recall raw score (p = .016) over 18 months, after controlling demographic characteristics, premorbid IQ, and changes in negative psychotic symptoms. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Total hours worked over 18 months was associated with small improvements on one test of processing speed and one test of working memory. However, total hours worked over 18 months was also associated with decline on one test of attention and working memory and visual organization and memory. The findings implicate that work alone may not be entirely effective in changing neurocognitive functioning for young people with first-episode psychosis. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The personal recovery movement in mental health has emphasised consumers' individual responsibility and autonomy in defining and directing their own recovery journey. Self-efficacy, or an individual's belief that they can achieve their desired outcomes, is likely to be a key predictor of recovery success. However, there is no established measure of self-efficacy for personal recovery. The Self-Efficacy for Personal Recovery Scale was developed and its psychometric properties evaluated as part of a broader research program investigating a recovery-focused digital intervention in psychosis. Scale reliability and validity were investigated in a sample of 178 adults with persisting psychosis, and test-retest reliability was evaluated in a subset of 32 participants. The scale showed high internal consistency, test-retest reliability, and convergent validity, including correlating positively with hope, personal recovery, and generalised self-efficacy, whilst showing independence from social desirability, insight, and positive symptoms. This measure may be useful for research into the processes underlying recovery, and for understanding how self-efficacy for personal recovery may be enhanced in people with severe mental illness.

Aim Most mental disorders have their onset by age 25, disrupting normative vocational engagement. Factors associated with vocational disengagement at first contact with specialist treatment are important for service planning. The aim of this paper was to investigate the association between theoretically important factors and vocational disengagement for youth entering mental health treatment. Methods A file audit was used to extract vocational data of 145 young people aged 15 to 25 years entering treatment in 2011 at a public youth mental health service in Melbourne, Australia. Comparisons were made across three specialist programs for: psychosis (n = 50), mood disorders (n = 52) and borderline personality pathology (n = 43). Individual characteristics were entered into univariate and multivariate logistic regressions to investigate their associations with vocational disengagement. Results Educational disengagement was associated with being older (OR = 4.38, P = 0.004) and not living with parents (OR = 2.87, P = 0.038). Unemployment and being NEET (Not in Education, Employment or Training) were both associated with not having commenced tertiary education (OR = 0.23, P = 0.022; OR = 0.05, P = 0.002; respectively). Being NEET was also associated with being older (OR = 6.18, P = 0.004). Primary diagnostic grouping was not associated with vocational disengagement, once accounting for other factors. Conclusions The likelihood of vocational disengagement did not differ across disorder groups, implying that intervention should be "transdiagnostic" and might best target education first, specifically post-secondary qualifications. Other domains or variables not measured in this study are also likely to be important, and this might include young people's support systems and symptom severity. Qualitative studies may be useful for exploring further factors relevant to vocational engagement.

AIM: To compare rates of vocational engagement for youth entering specialist mental health treatment with the general population. METHODS: A file audit retrieved vocational data for 145 youth aged 15 to 25 entering treatment. Clinical and population data were stratified by age and sex and compared between cohorts. RESULTS: Compared to the population, young people entering mental health treatment were less likely to have completed at least Year 11 in school (77% vs 42%, P

Aims.Clinical Practice Guidelines (CPGs) recommend evidence-based psychosocial interventions (EBPIs) to improve consumer recovery; however, availability appears limited. We describe receipt of six EBPIs, reported by people with psychoses, and associations with service and consumer characteristics, including indicators of need (eligibility) and benefit (suitability).Methods.Participants in the 2010 Australian national survey of psychosis (n= 1825) were interviewed to assess demographic, functional, mental and physical health characteristics and service use in the previous year. Six EBPIs (Cognitive Behaviour Therapy for psychosis; Family Psycho-Education (FPE); Relapse Prevention Planning (RPP); Skills Training; Supported Employment; and Assertive Community Treatment) were chosen, based on the strength and consistency of CPG recommendations. Associations between receipt of interventions and eligibility and suitability indicators were examined via correlations and χ2. Logistic regression was used to predict receipt of one or more EBPIs and to identify predictors of each individual EBPI.Results.Less than one-quarter of the sample reported receipt of an evidence-based level of any intervention: rates ranged from 3.4% (FPE) to 21.1% (RPP). The model predicting receipt of one or more EBPIs was statistically significant (χ2(20,n= 1746) = 216.12,p< 0.01) and marginally useful. Nine variables contributed uniquely, of which six were service characteristics. The strongest predictors of receipt were being assigned a psychologist as a case manager (p< 0.01, OR(CI) = 2.36(1.50–3.72)) and accessing a non-clinical mental health support service in the past year (p< 0.01, OR(CI) = 2.01(1.60–2.51)).Conclusions.Prior reports of limited receipt of EBPIs are reinforced. There is patchy evidence for targeting of EBPIs to those who might benefit most. Service characteristics contribute more to the prediction of receipt than clinical characteristics. Greater implementation effort and better targeting are required to bridge evidence-practice gaps, including improved evidence-based practice literacy among professionals and needs-based service re-design to improve provision and optimise consumer outcomes.

OBJECTIVE This study aimed to better understand the implementation of cognitive behavioral therapy for psychosis (CBTp) by exploring the impact of clinicians' attitudes toward CBTp within the Theory of Planned Behavior framework (i.e., by considering attitudes, behaviors, intention, and social norms) as well as perceived obstacles and response to proposed solutions. METHOD One hundred forty-two clinicians from 2 sites in Canada and 1 site in Australia answered an online survey involving both Likert scales and open-ended questions. The role of attitudes, social norms, and behavioral control (i.e., freedom to decide or act) on intention of offering CBTp delivering CBTp were analyzed using linear and logistic regressions. Sites were compared using analysis of variance. Reponses to perceived obstacles were thematically analyzed. RESULTS Results were similar across settings. Entered together in the model, attitudes, social norms, and behavioral control were significant in predicting the intention of offering CBTp, F(3, 125) = 38.49, p < .001, with 49% of the variance explained, although behavioral control did not significantly contribute to the model. CBTp training (odds ratio = 0.23, confidence interval = 0.06-0.58) and social norms (odds ratio = 0.79, confidence interval = 0.68-0.93) significantly predicted CBTp delivery. Six themes that emerged regarding perceived obstacles are provided. Training, supervision, and local support were the most frequently endorsed solutions. Brief or modular CBTp and group or online delivery were also positively endorsed. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Clinicians' individual and collective attitudes should be targeted by more and better training to increase their delivery of CBTp. Given organizational barriers, CBTp-informed interventions warrant further investigation. (PsycINFO Database Record

AIM: To examine whether baseline neurocognition predicts vocational outcomes over 18 months in patients with first-episode psychosis enrolled in a randomized controlled trial of Individual Placement and Support or treatment as usual. METHODS: One-hundred and thirty-four first-episode psychosis participants completed an extensive neurocognitive battery. Principal axis factor analysis using PROMAX rotation was used to determine the underlying structure of the battery. Setwise (hierarchical) multiple linear and logistic regressions were used to examine predictors of (1) total hours employed over 18 months and (2) employment status, respectively. Neurocognition factors were entered in the models after accounting for age, gender, premorbid IQ, negative symptoms, treatment group allocation and employment status at baseline. RESULTS: Five neurocognitive factors were extracted: (1) processing speed, (2) verbal learning and memory, (3) knowledge and reasoning, (4) attention and working memory and (5) visual organization and memory. Employment status over 18 months was not significantly predicted by any of the predictors in the final model. Total hours employed over 18 months were significantly predicted by gender (P = .027), negative symptoms (P = .032) and verbal learning and memory (P = .040). Every step of the regression model was a significant predictor of total hours worked overall (final model: P = .013). CONCLUSION: Verbal learning and memory, negative symptoms and gender were implicated in duration of employment in first-episode psychosis. The other neurocognitive domains did not significantly contribute to the prediction of vocational outcomes over 18 months. Interventions targeting verbal memory may improve vocational outcomes in early psychosis.

BackgroundThe efficacy of acceptance and commitment therapy (ACT) in psychosis has been reported but not for medication-resistant psychosis.AimsTo test the efficacy of ACT in a sample of community-residing patients with persisting psychotic symptoms. (Australian New Zealand Clinical Trials Registry: ACTRN12608000210370.)MethodThe primary outcome was overall mental state at post-therapy (Positive and Negative Syndrome Scale –total); secondary outcomes were psychotic symptom dimensions and functioning. In total, 96 patients were randomised to ACT (n = 49) or befriending (n = 47). Symptom, functioning and process measures were administered at baseline, post-therapy and 6 months later.ResultsThere was no group difference on overall mental state. In secondary analyses the ACT group showed greater improvement in positive symptoms and hallucination distress at follow-up: Cohen's d = 0.52 (95% CI 0.07–0.98) and 0.65 (95% CI 0.24–1.06), respectively.ConclusionsImprovements reflected the treatment focus on positive symptoms; however, absence of process-measure changes suggests that the ACT intervention used did not manipulate targeted processes beyond befriending. Symptom-specific therapy refinements, improved investigation of process and attention to cognitive functioning and dose are warranted in future research.

BackgroundRelapse prevention strategies based on monitoring of early warning signs (EWS) are advocated for the management of psychosis. However, there has been a lack of research exploring how staff, carers and patients make sense of the utility of EWS, or how these are implemented in context.AimsTo develop a multiperspective theory of how EWS are understood and used, which is grounded in the experiences of mental health staff, carers and patients.MethodTwenty-five focus groups were held across Glasgow and Melbourne (EMPOWER Trial, ISRCTN: 99559262). Participants comprised 88 mental health staff, 21 patients and 40 carers from UK and Australia (totaln= 149). Data were analysed using constructivist grounded theory.ResultsAll participants appeared to recognise EWS and acknowledged the importance of responding to EWS to support relapse prevention. However, recognition of and acting on EWS were constructed in a context of uncertainty, which appeared linked to risk appraisals that were dependent on distinct stakeholder roles and experiences. Within current relapse management, a process of weighted decision-making (where one factor was seen as more important than others) described how stakeholders weighed up the risks and consequences of relapse alongside the risks and consequences of intervention and help-seeking.ConclusionsMental health staff, carers and patients speak about using EWS within a weighted decision-making process, which is acted out in the context of relationships that exist in current relapse management, rather than an objective response to specific signs and symptoms.

Background Relapse is a common experience for people diagnosed with psychosis, which is associated with increased service costs and profound personal and familial distress. EMPOWER (Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery) is a peer worker–supported digital intervention that aims to enable service users to self-monitor their mental health with the aim of encouraging self-management and the shared use of personal data to promote relapse prevention. Digital interventions have not been widely used in relapse prevention and, therefore, little is currently known about their likely implementation—both within trials and beyond. Objective Seeking the perspectives of all relevant stakeholder groups is recommended in developing theories about implementation because this can reveal important group differences in understandings and assumptions about whether and for whom the intervention is expected to work. However, the majority of intervention implementation research has been retrospective. This study aimed to discover and theoretically frame implementation expectations in advance of testing and synthesize these data into a framework. Methods To develop a hypothetical implementation framework, 149 mental health professionals, carers, and people diagnosed with psychosis participated in 25 focus groups in both Australia and the United Kingdom. An interview schedule informed by the normalization process theory was used to explore stakeholders’ expectations about the implementation of the EMPOWER intervention. Data were analyzed using thematic analysis and then theoretically framed using the Medical Research Council guidelines for understanding the implementation of complex interventions. Results All groups expected that EMPOWER could be successfully implemented if the intervention generated data that were meaningful to mental health staff, carers, and service users within their unique roles. However, there were key differences between staff, carers, and service users about what facilitators and barriers that stakeholders believe exist for intervention implementation in both the cluster randomized controlled trial stage and beyond. For example, service user expectations mostly clustered around subjective user experiences, whereas staff and carers spoke more about the impact upon staff interactions with service users. Conclusions A hypothetical implementation framework synthesized from stakeholder implementation expectations provides an opportunity to compare actual implementation data gathered during an ongoing clinical trial, giving valuable insights into the accuracy of these stakeholders’ previous expectations. This is among the first studies to assess and record implementation expectations for a newly developed digital intervention for psychosis in advance of testing in a clinical trial. Trial Registration ISRCTN Registry ISRCTN99559262; http://www.isrctn.com/ISRCTN99559262

Background Individuals with psychosis demonstrate positive attitudes towards utilising digital technology in mental health treatment. Although preliminary research suggests digital interventions are feasible and acceptable in this population, little is known about how to best promote engagement with these resources. Candidate predictors include therapist support, sources of motivation and recovery style. Understanding what factors predict engagement will aid more effective design and implementation of digital interventions to improve clinical benefits. Objective This study aimed to investigate demographic, psychological, and treatment variables that predict overall and type of engagement with a psychosocial, online intervention for individuals with psychosis. Methods Ninety-eight participants with a history of psychosis were given access to a web program containing modules on self-management and recovery, which they were asked to use flexibly at their own pace. Activity was automatically logged by the system. Baseline measures of demographics, recovery style and motivation were administered, and participants were randomised to receive either website access alone, or website access plus weekly, asynchronous emails from an online coach over 12 weeks. Log and baseline assessment data were used in negative binomial regressions to examine predictors of depth and breadth of use over the intervention period. A logistic regression was used to examine the impact of predictor variables on usage profiles (active or passive). Results Depth and breadth of engagement were positively predicted by receiving email support, low levels of externally controlled motivations for website use, older age, and having a tertiary education. There was a significant interaction between level of controlled motivation and condition (+/−email) on breadth and depth of engagement: receiving asynchronous emails was associated with increased engagement for individuals with low, but not high, levels of externally controlled motivations. Receiving email support and more autonomous motivations for treatment predicted more active use of the website. Conclusions Asynchronous email support can promote engagement with online interventions for individuals with psychosis, potentially enabling self-management of illness and improving clinical outcomes. However, those using online interventions due to external motivating factors, may have low levels of engagement with the intervention, irrespective of coaching provided. These findings may guide design and implementation of future online interventions in this population., Highlights • Asynchronous email can promote engagement with online interventions for psychosis. • Individuals motivated by external factors (e.g., wanting to please others) are unlikely to have high levels of engagement. • Older age and a tertiary education were associated with higher levels of engagement amongst individuals with psychosis.

BACKGROUND Relapse is common in people who experience psychosis and is associated with many negative consequences, both societal and personal. People who relapse often exhibit changes (early warning signs [EWS]) in the period before relapse. Successful identification of EWS offers an opportunity for relapse prevention. However, several known barriers impede the use of EWS monitoring approaches. Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery (EMPOWER) is a complex digital intervention that uses a mobile app to enhance the detection and management of self-reported changes in well-being. This is currently being tested in a pilot cluster randomized controlled trial. As digital interventions have not been widely used in relapse prevention, little is known about their implementation. Process evaluation studies run in parallel to clinical trials can provide valuable data on intervention feasibility. OBJECTIVE This study aims to transparently describe the protocol for the process evaluation element of the EMPOWER trial. We will focus on the development of a process evaluation framework sensitive to the worldview of service users, mental health staff, and carers; the aims of the process evaluation itself; the proposed studies to address these aims; and a plan for integration of results from separate process evaluation studies into one overall report. METHODS The overall process evaluation will utilize mixed methods across 6 substudies. Among them, 4 will use qualitative methodologies, 1 will use a mixed methods approach, and 1 will use quantitative methodologies. RESULTS The results of all studies will be triangulated into an overall analysis and interpretation of key implementation lessons. EMPOWER was funded in 2016, recruitment finished in January 2018. Data analysis is currently under way and the first results are expected to be submitted for publication in December 2019. CONCLUSIONS The findings from this study will help identify implementation facilitators and barriers to EMPOWER. These insights will inform both upscaling decisions and optimization of a definitive trial. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/15634

BACKGROUND Relapse in schizophrenia is a major cause of distress and disability and is predicted by changes in symptoms such as anxiety, depression, and suspiciousness (early warning signs [EWSs]). These can be used as the basis for timely interventions to prevent relapse. However, there is considerable uncertainty regarding the implementation of EWS interventions. OBJECTIVE This study was designed to establish the feasibility of conducting a definitive cluster randomized controlled trial comparing Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery (EMPOWER) against treatment as usual (TAU). Our primary outcomes are establishing parameters of feasibility, acceptability, usability, safety, and outcome signals of a digital health intervention as an adjunct to usual care that is deliverable in the UK National Health Service and Australian community mental health service (CMHS) settings. We will assess the feasibility of candidate primary outcomes, candidate secondary outcomes, and candidate mechanisms for a definitive trial. METHODS We will randomize CMHSs to EMPOWER or TAU. We aim to recruit up to 120 service user participants from 8 CMHSs and follow them for 12 months. Eligible service users will (1) be aged 16 years and above, (2) be in contact with local CMHSs, (3) have either been admitted to a psychiatric inpatient service or received crisis intervention at least once in the previous 2 years for a relapse, and (4) have an International Classification of Diseases-10 diagnosis of a schizophrenia-related disorder. Service users will also be invited to nominate a carer to participate. We will identify the feasibility of the main trial in terms of recruitment and retention to the study and the acceptability, usability, safety, and outcome signals of the EMPOWER intervention. EMPOWER is a mobile phone app that enables the monitoring of well-being and possible EWSs of relapse on a daily basis. An algorithm calculates changes in well-being based on participants’ own baseline to enable tailoring of well-being messaging and clinical triage of possible EWSs. Use of the app is blended with ongoing peer support. RESULTS Recruitment to the trial began September 2018, and follow-up of participants was completed in July 2019. Data collection is continuing. The database was locked in July 2019, followed by analysis and disclosing of group allocation. CONCLUSIONS The knowledge gained from the study will inform the design of a definitive trial including finalizing the delivery of our digital health intervention, sample size estimation, methods to ensure successful identification, consent, randomization, and follow-up of participants, and the primary and secondary outcomes. The trial will also inform the final health economic model to be applied in the main trial. CLINICALTRIAL International Standard Randomized Controlled Trial Number (ISRCTN): 99559262; http://isrctn.com/ISRCTN99559262

BACKGROUND Relapse is a common experience for people diagnosed with psychosis, which is associated with increased service costs and profound personal and familial distress. EMPOWER (Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery) is a peer worker–supported digital intervention that aims to enable service users to self-monitor their mental health with the aim of encouraging self-management and the shared use of personal data to promote relapse prevention. Digital interventions have not been widely used in relapse prevention and, therefore, little is currently known about their likely implementation—both within trials and beyond. OBJECTIVE Seeking the perspectives of all relevant stakeholder groups is recommended in developing theories about implementation because this can reveal important group differences in understandings and assumptions about whether and for whom the intervention is expected to work. However, the majority of intervention implementation research has been retrospective. This study aimed to discover and theoretically frame implementation expectations in advance of testing and synthesize these data into a framework. METHODS To develop a hypothetical implementation framework, 149 mental health professionals, carers, and people diagnosed with psychosis participated in 25 focus groups in both Australia and the United Kingdom. An interview schedule informed by the normalization process theory was used to explore stakeholders’ expectations about the implementation of the EMPOWER intervention. Data were analyzed using thematic analysis and then theoretically framed using the Medical Research Council guidelines for understanding the implementation of complex interventions. RESULTS All groups expected that EMPOWER could be successfully implemented if the intervention generated data that were meaningful to mental health staff, carers, and service users within their unique roles. However, there were key differences between staff, carers, and service users about what facilitators and barriers that stakeholders believe exist for intervention implementation in both the cluster randomized controlled trial stage and beyond. For example, service user expectations mostly clustered around subjective user experiences, whereas staff and carers spoke more about the impact upon staff interactions with service users. CONCLUSIONS A hypothetical implementation framework synthesized from stakeholder implementation expectations provides an opportunity to compare actual implementation data gathered during an ongoing clinical trial, giving valuable insights into the accuracy of these stakeholders’ previous expectations. This is among the first studies to assess and record implementation expectations for a newly developed digital intervention for psychosis in advance of testing in a clinical trial. CLINICALTRIAL ISRCTN Registry ISRCTN99559262; http://www.isrctn.com/ISRCTN99559262

Cognitive impairment is common in first-episode psychosis (FEP); however, the relationship between duration of untreated psychosis (DUP) and neurocognition remains controversial, and no studies have examined the relationship between DUP and social cognition. This study involved secondary data analysis of baseline data from a randomised controlled trial of supported employment; 122 out 146 young people with FEP met inclusion criteria for this study. Results showed that DUP was not associated with neurocognitive or social cognitive performance. Results do not provide support for the neurotoxicity hypothesis of psychosis.

As digital interventions are beginning to be developed to support self-management of psychosis, it is important to understand how illness-related and individual factors may affect internet use and engagement with digital mental health resources among people with psychotic disorders. This study aimed to identify demographic, clinical, and personal variables associated with overall and mental health-related internet use in a sample of 189 adult community mental health service users with nonaffective and affective psychotic disorders. Among participants who regularly used the internet (87.3%), most (67.9%) reported using the internet for mental health information. Higher frequency of overall internet use was predicted by younger age, completion of post-secondary education, and less severe negative symptoms. Internet use for mental health information was predicted by younger age, higher levels of overall internet use, current productive employment, and higher loneliness. This study is the first to quantitatively examine how clinical and personal measures relate to overall and mental health-related internet use in people with psychosis. Although cognitive difficulties and negative symptoms impacted overall internet use, these disorder-related difficulties did not further impact internet use for mental health information. Digital mental health resources should be designed to optimise engagement for this population.

The Internet offers a growing range of e-mental health resources for people experiencing severe mental illness. How these resources may be used in face-to-face interactions with consumers in mental health practice is not well understood.This article explores mental health workers' current use of online resources and their views about integrating e-mental health resources for promoting self-management and recovery into community-based practice.A total of 37 mental health workers from six services attended focus groups to discuss their views about using online and e-mental health resources in face-to-face interactions with consumers. Data were analyzed using qualitative content analysis.Participants described accessing Internet information but having little opportunity to use online resources with consumers. Limited access to mobile technology and perceptions that consumers lacked technological experience constrained current use. Three approaches to using e-mental health resources were perceived: directing, collaborating, and empowering. Access to mobile technology within worker-consumer interactions was identified as a potential catalyst for creating recovery-oriented therapeutic relationships.Mental health workers are ready to grasp opportunities to use e-mental health resources with consumers. This has the potential to develop and strengthen collaborative, partnership-based relationships if mental health services support workers and consumers to use online resources together.

Background Internet-based interventions can make self-management and recovery-oriented information and tools more accessible for people experiencing severe mental illness, including psychosis. The aim of this scoping review was to identify and describe emerging joint uses of these Internet-based interventions by service users experiencing psychosis and mental health workers. It also investigated how using these Internet-based interventions influenced interactions between service users and workers and whether recovery-oriented working practices were elicited. Methods A scoping review method was used. Iterative review stages included identifying the review question, a comprehensive search including searching six electronic databases to locate relevant studies, selecting studies, charting the data, and collating and reporting the results. Rigour of the scoping review was enhanced by using an appraisal tool to evaluate the quality of included studies, and by using a published template for systematic description of interventions. Results Fifteen papers about eleven Internet-based interventions that focused on self-management and/or recovery were identified. Interventions were web-based, mobile-device based, or both. The eleven interventions were used by service users either with their usual mental health workers, or with mental health workers employed in a research project. Emerging evidence suggested that jointly using an Internet-based intervention could support a positive sense of working together. However, mismatched expectations and poor integration of Internet-based interventions into service systems could also negatively influence interactions, leading to mistrust. The interventions demonstrated potential to elicit recognised recovery-oriented practices, specifically understanding service users’ values and supporting their goal striving. Conclusions The use of Internet-based interventions focused on self-management and recovery in mental health services by service users and workers jointly demonstrates potential to support working together and recovery-oriented practice. Given that the quality of relationships is critical in recovery-oriented practice, greater focus on human support in Internet-based interventions is needed in future research and practice. Electronic supplementary material The online version of this article (10.1186/s12888-019-2153-0) contains supplementary material, which is available to authorized users.