Internet Use May Trigger Psychosis Relapse

Liam Davenport

April 09, 2018

FLORENCE, Italy — A substantial proportion of patients with psychosis have had bad experiences online and are suspicious of the Internet, and in some cases Internet use triggers psychosis relapses, warn Spanish researchers.

The survey of almost 100 patients with psychosis showed that about 20% of patients feel suspicious about the Internet while almost 40% have had bad experiences online.

The results also indicated that the frequency of Internet access and having a social media account were linked to Internet-related psychosis relapses and pathologic Internet use.

"Younger patients, recent diagnosis of psychosis, and being in a nonactive employment situation seem to be related to these pathological results too," say Julio Sanjuan, MD, professor of psychiatry, University of Valencia School of Medicine, Valencia, Spain, and colleagues.

"These findings suggest that, although technology is widely accepted by patients, the Internet is a source of information that could be interpreted as a false alarm signal that may trigger paranoid symptoms."

The study was presented here at the Schizophrenia International Research Society (SIRS) 2018 Biennial Meeting.

Smart Phone Apps Promising

However, one way that the Internet could be used in a positive way is via smartphone apps that regularly ask patients with psychosis about their symptoms and then alert healthcare professionals if personalized threshold are exceeded. One platform has shown significant improvements in symptoms.

Sanjuan told Medscape Medical News that he undertook the study because he and his colleagues are trying to develop an application for patients with psychosis. They reviewed all the currently available applications and associated Internet-related issues.

Because this review showed that some patients had bad experiences online, the team designed a structured questionnaire that gathered clinical and demographic information and asked about access to and use of technologies and respondents' experiences with and opinions of the Internet.

Ninety-seven outpatients with psychotic disorder took part. The mean age was 37.1 years; 72.2% of patients were male, 84.5% were single, and 60.8% had achieved at least secondary education.

The most common diagnoses were first episode psychosis (45.5%) and schizophrenia (34.0%), and the duration of illness was less than 72 months in the majority of patients (64.9%).

Daily access to the Internet was reported by 63.9% of patients, while 21.6% accessed it weekly. The team found that 90.7% of patients owned a mobile phone and 68.0% had a social media account.

In 60.8% of cases, participants reported that using the Internet made them feel socially connected, and 78.4% felt informed. However, 22.7% reported feeling frustrated by their Internet use and 19.6% felt suspicious of it.

In terms of feelings related to Internet use, the only significant association was between feeling informed and the frequency of Internet access (P = .05).

Turning to online experiences, the team found that 46.4% of patients thought the Internet was a benefit to mental health, while 38.1% had had unpleasant experiences online; 24.7% had had Internet-related psychotic relapses and 26.8% reported spending excessive time online.

Internet-related relapses were significantly associated with the length of illness (P = 0.03), frequency of Internet access (P < .001), and having social media accounts (P = .02).

Excessive Internet use was significantly associated with age (P = .04), employment status (P = .03), frequency of Internet access (P  < .001), and having a social media account (P < .01).

There was also a significant association between stopping taking medication because of information read on the Internet and level of education (P < .01).

Bad Online Experience

Sanjuan believes it would be "difficult" to teach patients who have had a bad online experience to use the Internet in a more constructive manner "because they are paranoid of it; they don't use it all."

However, he added that "luckily, about 65% or 70% of patients believe they could have [a good experience]."

"But the interesting thing that's not in the poster but we found in the survey is that, for most of the patients, the most important thing about the use of the Internet or cell phones is not information but to increase adherence with the clinician, to have a way to ask questions or just have an alarm button," said Sanjuan.

He said, "today, everybody is talking about the adherence problem," so perhaps this would be the most beneficial way to use the Internet in these patients.

This impression was borne out in a presentation given at the SIRS meeting by Shôn W. Lewis, MD, PhD, professor of adult psychiatry at the University of Manchester, United Kingdom, who discussed results from two studies on the use of smartphone applications in psychosis management.

He said that he first had the idea to develop a smartphone app at the SIRS meeting 10 years ago, and, since then, he and his colleagues have created ClinTouch for patients with serious mental illness. The app  is available on the iOS and Android platforms.

Lewis explained that it beeps at semi-random intervals four to six times a day and asks the patient 13 or 14 questions on their current and recent symptoms, primarily based on Positive and Negative Syndrome Scale (PANSS) items, which takes around 70 seconds to complete.

The patient's response is then "wirelessly uploaded in real-time to a central server, which quite quickly builds up a high resolution picture of how your symptoms vary hour by hour."

The standalone version of the app builds graphs of symptom progression, among other measures, which can be shared with family and friends, as well as healthcare professionals.

However, it has also been embedded into hospitals in Manchester and London, where the data are included in electronic care records and made available for clinicians and healthcare staff to review.

With personalized alerts if certain thresholds are exceeded, "then the team can intervene very early in the prodromal symptoms of relapse," Lewis said.

Feasible, Acceptable

Having initially shown that most questions have good correlation with a week's worth of PANSS interviews, the team randomly assigned 81 patients to either standard care plus ClinTouch active symptom monitoring or standard care alone.

They found high acceptability and feasibility for the app over 12 weeks, with 84% of patients having a response rate of over 33%, and 100% of healthcare professionals accessing the system. However, two patients reported increases in anxiety and paranoia with app use.

Although the results in the overall patient group were not significant, when the team restricted the analysis to 44 patients with early psychosis, they found that the use of the ClinTouch app was associated with significant improvements in positive PANSS symptoms vs standard care alone, at an average of –3.0.

From this platform, the researchers created Actissist, which added an intervention based on cognitive-behavioral therapy (CBT), alongside a toolkit "including daily diaries, a relaxation area with personalized pieces of music or images, psychoeducation, soothing stuff, and feedback on how your mood is impacted by these various things," Lewis said.

In a study, published online in Schizophrenia Bulletin on March 16, the researchers randomly assigned 36 patients with early psychosis in a 2:1 fashion to Actissist or ClinTouch, plus standard care.

They found that Actissist significantly improved negative scores in comparison with ClinTouch by an average of –3.0, while general scores improved by a mean of –6.2 and total scores by an average of –10.5.

In addition, Calgary Depression Scale for Schizophrenia total scores were improved by an average of –3.4 with Actissist vs ClinTouch.

Lewis concluded that both interventions "are feasible to integrate into clinical workflows, they are very acceptable to patients and services, they are safe, and they appear to be efficacious."

He continued: "Efficacious in terms of self-management of positive symptoms, they can detect personalized relapse signatures, or early warning signs for relapse, and the CBT-informed version Actissist appears to have a significant effect on negative symptoms and mood."

Noting that larger trials of the platforms are already underway, he said, "One way of looking at this, thinking back to how ClinTouch didn't really have an impact in the more chronic patients, is that, just like drug and psychological treatments, it may be that digital treatments also work better in people with early psychosis."

Julio Sanjuan declared no conflicts of interest. Sh ô n Lewis declared confidential disclosure agreements with Otsuka Digital, Janssen, and Microsoft Research; research funding from the Medical Research Council, European Union, and National Institute of Health Research; and being medical director of Xenzone.com and Founding Director of not-for-profit start-up Affigo.io. The studies Lewis presented were funded by the Medical Research Council.

Schizophrenia International Research Society (SIRS) 2018 Biennial Meeting. Poster S249 and Abstract O11.1. Presented April 7, 2018.

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