Research paper
Psychoeducation in bipolar disorder with a SIMPLe smartphone application: Feasibility, acceptability and satisfaction

https://doi.org/10.1016/j.jad.2016.04.042Get rights and content

Highlights

  • The feasibility of a psychoeducation application was evaluated during 3 months.

  • A representative sample of 52 bipolar disorder patients were included.

  • Three-quarters of the patients enrolled remained actively using the application.

  • 86% agreed the experience using the application was acceptable and satisfactory.

  • Randomized clinical trials still needs to evaluate its efficacy to prevent relapses.

Abstract

Background

During the last fifteen years, the possibility of delivering psychoeducation programs through Internet-based platforms have been explored. Studies evaluating those programs have shown good to acceptable retention rates. In this context, we developed a smartphone application (SIMPLe) collecting information about mood symptoms and offering personalized psychoeducation messages. The main aims of this study were to evaluate the feasibility, acceptability and satisfaction of the smartphone application.

Methods

The study was conducted from March to August 2015. Participation in the study was proposed to a consecutive sample of adult patients attending an outpatient mental health clinic. Sociodemographic data, clinical and functional assessments alongside smartphone ownership and uses were collected at baseline and at 3 months' follow-up. A 5 item Likert-scale satisfaction questionnaire was also employed.

Results

51 participants were initially enrolled in the study, 36 (74%) remained actively using the application after 3 months. The whole sample interacted with the application a mean of 77 days (SD=26.2). During these days they completed 88% of the daily tests. Over 86% of the participants agreed that the experience using the application was satisfactory.

Limitations

The diversity of smartphones operating systems led to a moderate, although representative, sample number. Additionally, the subjective data reporting, narrow time frame of use and stability of the patients could have affected the results.

Conclusions

The results confirm that this particular intervention is feasible and represent a satisfactory and acceptable instrument for the self-management of bipolar disorder as an add-on to the usual treatment but future clinical trials must still probe its efficacy.

Introduction

The estimated prevalence of bipolar disorder (BD) in the general population is estimated to be around 2%, although this could have been underestimated due to undiagnosed cases (Fagiolini et al., 2013). Besides the well-known behavior changes during pathological mood episodes, BD has a serious impact on psychosocial functioning, cognition, quality of life and survival of those affected (Catalá-López et al., 2013). Some pharmacological treatments and adjunctive psychological interventions have shown to improve the long-term outcome of the disorder (Grunze et al., 2013, Reinares et al., 2014).

Among psychological interventions, psychoeducational programs proved to be a cost-effective approach to help patients improve adherence, regularity of habits and recognize early signs and symptoms in order to prevent episodes (Colom et al., 2009, Scott et al., 2009). However, although there is an increasing demand from patients and their relatives to receive this kind of treatments, its availability is still limited due to the costs and resources involved (Miklowitz and Scott, 2009). The implementation of psychoeducation programs require trained specialists and specialized units (Colom, 2011). Unfortunately, this combination is available only at very few centers around the globe. Moreover, from the patients' side, it requires attendance to weekly sessions during a period of about 6 months. This may limit its implementation in large countries and rural areas with long geographical distances between the patient and the care center. Besides the aforementioned challenges, tailoring these interventions to individual clinical characteristics and schedules in a cost-effective way are difficult aims yet to be addressed. For these reasons, there is an increasing need to find new efficient methods to deliver and extend psychoeducation programs to a wider population of patients with BD.

During the last fifteen years, several projects have explored the possibility of delivering psychoeducation programs through Internet-based platforms such as web-sites and mobile devices (Cosgrove et al., 2013, Depp et al., 2014, Meiser et al., 2013). These platforms offer the patients the possibility to access the program according to their schedules even if they live in remote areas, something which represents a very attractive complement to the standard treatment (Holländare et al., 2015, Palmier-Claus et al., 2013, Parmanto et al., 2013). Studies evaluating these programs have shown good to acceptable retention rates of about 50–80%; however, due to the extreme heterogeneity in outcome measures and methodologies used, it is still not possible to draw sound conclusions about their long-term efficacy (Hidalgo-Mazzei et al., 2015a).

On the other hand, the wide availability, constant miniaturization and increasing computing power of mobile devices make it possible to obtain a reliable and continuous collection of relevant users´ information at a low-cost. Smartphones, through the increasing embedded sensors and daily usage patterns, can collect a vast amount of objective information to identify behavioral symptoms patterns as well as physiological signs, which have the potential to provide novel insights about mental illnesses (Munk-Jørgensen et al., 2014). Moreover, this still underutilized kind of data have recently shown to be a feasible potential biomarker of illness activity in BD (Faurholt-Jepsen et al., 2015, Faurholt-Jepsen et al., 2014).

Based on an increasing number of studies, it seems that smartphones technology is perceived by the patients as a comfortable, time-unconstrained, user-friendly and non-invasive method in the self-management of their mental health (Bush et al., 2013). Furthermore, it makes possible to register and monitor relevant signs and symptoms in real-time (Faurholt-Jepsen et al., 2015). In addition, it can provide continuous self-managed psychoeducational contents, which can be tailored to the specific needs of each individual based on their smartphone data (Ben-Zeev et al., 2013, Torous et al., 2015).

As an initial phase of the SIMPLe project (Hidalgo-Mazzei et al., 2015a), we initially set out to develop a smartphone application (SIMPLe 1.0) collecting information about potential bipolar symptomatology (i.e. subjective information), with the additional advantage of offering personalized psychoeducation messages and alerts delivered to the patient. The application is intended to be an additional tool to the usual treatment. Before testing its efficacy and due to the novelty of the intervention, it is mandatory to carry out a rigorous feasibility study in a real-world clinical setting in order to ensure the acceptability, satisfaction and safety of these interventions and increase the chances of reaching some degree of engagement in the long term (Bowen et al., 2009, Wenze et al., 2014).

Accordingly, the main aims of this feasibility study were to evaluate, during 3 months, acceptability, safety and satisfaction of the SIMPLe smartphone application designed to monitor symptoms in BD, offering customized embedded psychoeducation contents and empowering self-management. Secondary objectives were to explore whether sociodemographic and clinical variables of the sample could predict or enhance the usage of this application. Additionally, patients' suggestions and comments regarding the application were collected during the study in order to improve further versions.

Section snippets

Participants, procedure and measures

The study was conducted from March to August 2015. Participation in the study was proposed to a consecutive sample of adult patients attending the outpatient mental health clinic of the Bipolar Disorders Program in the Hospital Clínic of Barcelona. The eligibility criteria included a diagnosis of a BD type I, II or not elsewhere specified (NES) based on DSM-5 criteria. The study was approved by the Ethics Committee of the Hospital Clínic of Barcelona and registered at clinicaltrials.gov

Sociodemographic and clinical characteristics of the sample

Out of 85 individuals offered to participate in the study, 51 were initially enrolled. A flowchart of the study is depicted in Fig. 3, including the main reasons of refusal to participate from the 34 eligible non-participants. Non-participants had a mean age of 44.5 years (standard deviation, SD=12.9) and there was a predominance of women (69.4%). Two patients accepted to participate but never installed the application, hence these users were not considered in the analyses.

The baseline

Discussion

To our knowledge, this is the first study to evaluate the feasibility of mood monitoring and providing personalized psychoeducation in BD through a smartphone application independently of a face-to-face psychoeducational program. The results confirm that this particular intervention is feasible and represent a satisfactory and acceptable instrument for self-management of BD as an add-on to the usual treatment. Furthermore, the ecological momentary assessments embedded in the application,

Limitations

Several limitations from both the intervention and the study methodology have to be considered. Taking into account the nature of the intervention, results could have been influenced by the so-called “technological generation gap”. However, given the very similar mean ages between participants and non-participants as well as completers and non-completers, this does not seem to have been a crucial issue in our study. In terms of the application, it was only available for Google™'s Android

Conclusions

Despite the aforementioned limitations, SIMPLe 1.0 has proven to be a feasible intervention that, if it proves its prophylactic effects, may extend the options to offer evidence-based psychoeducation for BD regardless of their sex, age or functional status. However, its efficacy and effectiveness as an add-on treatment still needs to be evaluated in randomized controlled clinical trials. Finally, this study is an example of technology use for healthcare improvement. These initiatives may give

Role of funding source

This project was supported by research grants from the Spanish Ministry of Economy and Competitiveness PI14/00286 and PI15/00588, Instituto de Salud Carlos III, Subdirección General de Evaluación y Fomento de la Investigación; Fondo Europeo de Desarrollo Regional. Unión Europea, “Una manera de hacer Europa” (to FC and JS). Other sources of indirect support are a Río Hortega grant (CM15/00127) from Instituto de Salud Carlos III (to DH), a Beatriu de Pinós grant from Secretaria d’ Universitats I

Contributors and Acknowledgments

Diego Hidalgo-Mazzei, Ainoa Mateu and Francesc Colom designed the study protocol. Diego Hidalgo-Mazzei, Cristina Varo, María Reinares and Marc Valentí conducted the recruitment and enrollment of the patients. Diego Hidalgo-Mazzei and Caterina del Mar Bonnín conducted the statistical analysis. Diego Hidalgo-Mazzei, María Reinares, Andrea Murru, Ainoa Mateu and Juan Undurraga wrote the first draft of the manuscript. Afterwards, Sergio Strejilevich, José Sánchez-Moreno, Eduard Vieta and, finally,

Conflict of Interest

DH, AM, MR, EV and FC have designed the SIMPLe smartphone application mentioned in this manuscript. The authors declare no other conflict of interests regarding this manuscript. The authors do not have any current or future economic interest in the SIMPLe application, its use or copyrights.

References (61)

  • A.M.A. Nivoli et al.

    New treatment guidelines for acute bipolar mania: a critical review

    J. Affect. Disord.

    (2012)
  • J. Proudfoot et al.

    Effects of adjunctive peer support on perceptions of illness control and understanding in an online psychoeducation program for bipolar disorder: a randomised controlled trial

    J. Affect. Disord.

    (2012)
  • M. Reinares et al.

    Psychosocial interventions in bipolar disorder: what, for whom, and when

    J. Affect. Disord.

    (2014)
  • W.R. Roth et al.

    Practical considerations in the design and development of smartphone apps for behavior change

    J. Context. Behav. Sci.

    (2014)
  • N.J. Todd et al.

    A web-based self-management intervention for bipolar disorder “living with bipolar”: a feasibility randomised controlled trial

    J. Affect. Disord.

    (2014)
  • N.J. Todd et al.

    An online randomised controlled trial to assess the feasibility, acceptability and potential effectiveness of “Living with Bipolar”: a web-based self-management intervention for bipolar disorder: trial design and protocol

    Contemp. Clin. Trials

    (2012)
  • C.W. Barnes et al.

    A web-based preventive intervention program for bipolar disorder: outcome of a 12-month randomized controlled trial

    J. Affect. Disord.

    (2014)
  • D. Ben-Zeev et al.

    Smartphones for smarter delivery of mental health programs: a systematic review

    JITA-J. Inf. Technol. Appl.

    (2013)
  • T.J. Brigham

    An introduction to gamification: adding game elements for engagement

    Med. Ref. Serv. Q.

    (2015)
  • N.E. Bush et al.

    Behavioral screening measures delivered with a smartphone app: psychometric properties and user preference

    J. Nerv. Mental Dis.

    (2013)
  • F. Colom

    Keeping therapies simple: psychoeducation in the prevention of relapse in affective disorders

    Br. J. Psychiatry

    (2011)
  • F. Colom E. Vieta Convivir con el Trastorno Bipolar PANAMERICANA, Madr....
  • F. Colom et al.

    Psychoeducation efficacy in bipolar disorders: beyond compliance enhancement

    J. Clin. Psychiatry

    (2003)
  • F. Colom et al.

    Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial

    Br. J. Psychiatry

    (2009)
  • Cosgrove, V., Fischer, E., Lauder, S., Gwizdowski, I., Feldman, N., Berk, M., Gliddon, E., Suppes, T., 2013. An online...
  • C.A. Depp et al.

    Augmenting psychoeducation with a mobile intervention for bipolar disorder: a randomized controlled trial

    J. Affect. Disord.

    (2014)
  • U.W. Ebner-Priemer et al.

    Ecological momentary assessment of mood disorders and mood dysregulation

    Psychol. Assess.

    (2009)
  • M. Faurholt-Jepsen et al.

    Daily electronic monitoring of subjective and objective measures of illness activity in bipolar disorder using smartphones¿ the MONARCA II trial protocol: a randomized controlled single-blind parallel-group trial

    BMC Psychiatry

    (2014)
  • M. Faurholt-Jepsen et al.

    Smartphone data as an electronic biomarker of illness activity in bipolar disorder

    Bipolar Disord.

    (2015)
  • H. Grunze et al.

    The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2012 on the long-term treatment of bipolar disorder

    World J. Biol. Psychiatry

    (2013)
  • Cited by (84)

    View all citing articles on Scopus
    View full text