Schizophrenia relapses are common, have profound, adverse consequences for patients and are costly to health services. Early signs interventions aim to use warning signs of deterioration to prevent full relapse. Such interventions show promise but could be further developed. The current paper addresses two developments: adding basic symptoms to checklists of conventional early signs; using a smartphone app (ExPRESS) to aid early signs monitoring.
1. Design a pool of self-report items assessing basic symptoms (Basic Symptoms Checklist, BSC); 2. Develop and usability-test a smartphone app (ExPRESS) for monitoring early signs, basic symptoms and psychotic symptoms; 3. Evaluate the long-term acceptability of ExPRESS by gathering qualitative feedback from participants in a six-month feasibility study.
The BSC items and ExPRESS app (adapted from ClinTouch app) were developed and then adjusted following feedback from usability testers (n=5) with a schizophrenia diagnosis. Individuals (n=18) experiencing a relapse of schizophrenia within the past year were asked to use ExPRESS for 6 months to answer weekly questions about their experience of early signs, basic symptoms and psychotic symptoms. At the end of follow-up, face-to-face qualitative interviews (n=16; two were uncontactable) explored experiences of using ExPRESS. The topic guide sought participants’ views on the following a priori themes regarding app acceptability: item content, layout and wording; app appearance; length and frequency of assessments; worries about app use; how app use fitted with participants’ routines; the app’s extra features. Interview transcripts were analyzed using the framework method which allows examination of both a priori and a posteriori themes, enabling unanticipated aspects of app use experiences to be explored.
Participants had a mean age of 38 (range 22-57). Participants’ responses to a priori topics indicated that long-term use of ExPRESS was acceptable; they suggested small changes that could be made for future versions of the app. A posteriori themes gave further insight into individuals’ experiences of using ExPRESS. Some participants reported finding it more accessible than visits from a clinician, since assessments were more frequent, more anonymous and did not require the individual to explain their feelings in their own words. Nevertheless, barriers to app use (e.g. unfamiliarity with smartphones) were also reported. Despite the app containing no overtly therapeutic components, some participants found that answering weekly questions on the app prompted self-reflection which had therapeutic value for them.
This study suggests that apps are an acceptable means of long-term symptom monitoring for individuals with a schizophrenia diagnosis across a wide age range. As long as the potential benefits are understood, patients are generally willing and motivated to use a weekly symptom-monitoring app; virtually all participants in the current study were prepared to do so for more than six months.