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      How Inclusive, User-Centered Design Research Can Improve Psychological Therapies for Psychosis: Development of SlowMo

      research-article
      , BSc (Hons), PhD, DClinPsy 1 , 2 , , , MA, MSc 3 , , BEng (Hons), MA, DIC 3 , , BSc (Hons), MDesRCA 3 , , BSc (Hons), PhD 4 , , MSci, DClinPsy 1 , 2 , , BA (Hons), MSc 5 , , BA (Hons), PhD, DClinPsy, FBPsS 6 , , BSc (Hons), PhD, DClinPsy 2 , , OBE, BSc (Hons), PhD, FBPsS, FAcSS 1 , 2 , , MA, MB, BChir, MPhil, PhD, FRCP, FRCPsych 7 , , MSc 8 , , BSc (Hons), PhD, GradStat 9 , , MA, MSc, PhD, FRSB 10 , , PhD, CPsychol, FBPsS 1 , 2
      (Reviewer), (Reviewer)
      JMIR Mental Health
      JMIR Publications
      inclusive design, user-centered design, participatory design, design thinking, mHealth, eHealth, digital therapy, schizophrenia, paranoia, psychosis

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          Abstract

          Background

          Real-world implementation of psychological interventions for psychosis is poor. Barriers include therapy being insufficiently usable and useful for a diverse range of people. User-centered, inclusive design approaches could improve the usability of therapy, which may increase uptake, adherence, and effectiveness.

          Objective

          This study aimed to optimize the usability of an existing psychological intervention, Thinking Well, which targets reasoning processes in paranoia using a basic digital interface.

          Methods

          We conducted inclusive, user-centered design research characterized by purposive sampling of extreme users from the margins of groups, ethnographic investigation of the problem context, and iterative prototyping of solutions. The UK Design Council’s double diamond method was used. This consisted of 4 phases: discover, including a case series of Thinking Well, stakeholder interviews, desk research, user profiling, system mapping, and a mood board; define, consisting of workshops to synthesize findings and generate the design brief; develop, involving concept workshops and prototype testing; and deliver, in which the final minimal viable product was storyboarded and iteratively coded.

          Results

          Consistent with our previous work, the Thinking Well case series showed medium to large effects on paranoia and well-being and small effects on reasoning. These were maintained at follow-up despite some participants reporting difficulties with the therapy interface. Insights from the discover phase confirmed that usability was challenged by information complexity and poor accessibility. Participants were generally positive about the potential of technology to be enjoyable, help manage paranoia, and provide tailored interpersonal support from therapists and peers, although they reported privacy and security concerns. The define phase highlighted that the therapy redesign should support monitoring, simplify information processing, enhance enjoyment and trust, promote personalization and normalization, and offer flexible interpersonal support. During the develop phase over 60 concepts were created, with 2 key concepts of thoughts visualized as bubbles and therapy as a journey selected for storyboarding. The output of the deliver phase was a minimal viable product of an innovative digital therapy, SlowMo. SlowMo works by helping people to notice their worries and fast thinking habits, and encourages them to slow down for a moment to find ways of feeling safer. A Web app supports the delivery of 8 face-to-face sessions, which are synchronized to a native mobile app.

          Conclusions

          SlowMo makes use of personalization, ambient information, and visual metaphors to tailor the appeal, engagement, and memorability of therapy to a diversity of needs. Feasibility testing has been promising, and the efficacy of SlowMo therapy is now being tested in a multicentered randomized controlled trial. The study demonstrates that developments in psychological theory and techniques can be enhanced by improving the usability of the therapy interface to optimize its impact in daily life.

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          Most cited references33

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          Accelerating Digital Mental Health Research From Early Design and Creation to Successful Implementation and Sustainment

          Mental health problems are common and pose a tremendous societal burden in terms of cost, morbidity, quality of life, and mortality. The great majority of people experience barriers that prevent access to treatment, aggravated by a lack of mental health specialists. Digital mental health is potentially useful in meeting the treatment needs of large numbers of people. A growing number of efficacy trials have shown strong outcomes for digital mental health treatments. Yet despite their positive findings, there are very few examples of successful implementations and many failures. Although the research-to-practice gap is not unique to digital mental health, the inclusion of technology poses unique challenges. We outline some of the reasons for this gap and propose a collection of methods that can result in sustainable digital mental health interventions. These methods draw from human-computer interaction and implementation science and are integrated into an Accelerated Creation-to-Sustainment (ACTS) model. The ACTS model uses an iterative process that includes 2 basic functions (design and evaluate) across 3 general phases (Create, Trial, and Sustain). The ultimate goal in using the ACTS model is to produce a functioning technology-enabled service (TES) that is sustainable in a real-world treatment setting. We emphasize the importance of the service component because evidence from both research and practice has suggested that human touch is a critical ingredient in the most efficacious and used digital mental health treatments. The Create phase results in at least a minimally viable TES and an implementation blueprint. The Trial phase requires evaluation of both effectiveness and implementation while allowing optimization and continuous quality improvement of the TES and implementation plan. Finally, the Sustainment phase involves the withdrawal of research or donor support, while leaving a functioning, continuously improving TES in place. The ACTS model is a step toward bringing implementation and sustainment into the design and evaluation of TESs, public health into clinical research, research into clinics, and treatment into the lives of our patients.
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            Mobile Assessment and Treatment for Schizophrenia (MATS): a pilot trial of an interactive text-messaging intervention for medication adherence, socialization, and auditory hallucinations.

            Mobile Assessment and Treatment for Schizophrenia (MATS) employs ambulatory monitoring methods and cognitive behavioral therapy interventions to assess and improve outcomes in consumers with schizophrenia through mobile phone text messaging. Three MATS interventions were developed to target medication adherence, socialization, and auditory hallucinations. Participants received up to 840 text messages over a 12-week intervention period. Fifty-five consumers with schizophrenia or schizoaffective disorder were enrolled, but 13 consumers with more severe negative symptoms, lower functioning, and lower premorbid IQ did not complete the intervention, despite repeated prompting and training. For completers, the average valid response rate for 216 outcome assessment questions over the 12-week period was 86%, and 86% of phones were returned undamaged. Medication adherence improved significantly, but only for individuals who were living independently. Number of social interactions increased significantly and a significant reduction in severity of hallucinations was found. In addition, the probability of endorsing attitudes that could interfere with improvement in these outcomes was also significantly reduced in MATS. Lab-based assessments of more general symptoms and functioning did not change significantly. This pilot study demonstrated that low-intensity text-messaging interventions like MATS are feasible and effective interventions to improve several important outcomes, especially for higher functioning consumers with schizophrenia.
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              Psychological interventions for psychosis: a meta-analysis of comparative outcome studies.

              Meta-analyses have demonstrated the efficacy of various interventions for psychosis, and a small number of studies have compared such interventions. The aim of this study was to provide further insight into the relative efficacy of psychological interventions for psychosis. Forty-eight outcome trials comparing psychological interventions for psychosis were identified. The comparisons included 3,295 participants. Categorization of interventions resulted in six interventions being compared against other interventions pooled. Hedges' g was calculated for all comparisons. Risk of bias was assessed using four items of the Cochrane risk of bias tool, and sensitivity analyses were conducted. Researcher allegiance was assessed, and sensitivity analyses were conducted for robust significant findings. Cognitive-behavioral therapy (CBT) was significantly more efficacious than other interventions pooled in reducing positive symptoms (g=0.16). This finding was robust in all sensitivity analyses for risk of bias but lost significance in sensitivity analyses for researcher allegiance, which suffered from low power. Social skills training was significantly more efficacious in reducing negative symptoms (g=0.27). This finding was robust in sensitivity analyses for risk of bias and researcher allegiance. Significant findings for CBT, social skills training, and cognitive remediation for overall symptoms were not robust after sensitivity analyses. CBT was significantly more efficacious when compared directly with befriending for overall symptoms (g=0.42) and supportive counseling for positive symptoms (g=0.23). There are small but reliable differences in efficacy between psychological interventions for psychosis, and they occur in a pattern consistent with the specific factors of particular interventions.
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                Author and article information

                Contributors
                Journal
                JMIR Ment Health
                JMIR Ment Health
                JMH
                JMIR Mental Health
                JMIR Publications (Toronto, Canada )
                2368-7959
                Oct-Dec 2018
                05 December 2018
                : 5
                : 4
                : e11222
                Affiliations
                [1 ] Department of Psychology Institute of Psychiatry, Psychology & Neuroscience King's College London London United Kingdom
                [2 ] South London & Maudsley NHS Foundation Trust London United Kingdom
                [3 ] Helen Hamlyn Centre for Design Royal College of Art London United Kingdom
                [4 ] Evolyst Limited Warwick United Kingdom
                [5 ] Department of Psychology Royal Holloway Egham United Kingdom
                [6 ] Department of Psychiatry University of Oxford Oxford United Kingdom
                [7 ] Division of Psychiatry University College London London United Kingdom
                [8 ] Department of Psychology University of Sussex Sussex United Kingdom
                [9 ] Department of Biostatistics and Health Informatics Institute of Psychiatry, Psychology & Neuroscience King's College London London United Kingdom
                [10 ] School of Health Sciences University of Manchester Manchester United Kingdom
                Author notes
                Corresponding Author: Amy Hardy amy.hardy@ 123456kcl.ac.uk
                Author information
                http://orcid.org/0000-0002-6044-6093
                http://orcid.org/0000-0003-4702-7473
                http://orcid.org/0000-0003-3972-1158
                http://orcid.org/0000-0001-6228-9100
                http://orcid.org/0000-0002-3303-3293
                http://orcid.org/0000-0002-7608-5755
                http://orcid.org/0000-0002-4860-7595
                http://orcid.org/0000-0002-2541-2197
                http://orcid.org/0000-0001-5766-0972
                http://orcid.org/0000-0002-0041-7338
                http://orcid.org/0000-0002-6030-7456
                http://orcid.org/0000-0001-5806-2659
                http://orcid.org/0000-0002-1218-675X
                http://orcid.org/0000-0001-7091-3161
                http://orcid.org/0000-0002-5637-1340
                Article
                v5i4e11222
                10.2196/11222
                6300708
                30518514
                6c07de79-85dc-4147-8cf9-57c5058e93bb
                ©Amy Hardy, Anna Wojdecka, Jonathan West, Ed Matthews, Christopher Golby, Thomas Ward, Natalie D Lopez, Daniel Freeman, Helen Waller, Elizabeth Kuipers, Paul Bebbington, David Fowler, Richard Emsley, Graham Dunn, Philippa Garety. Originally published in JMIR Mental Health (http://mental.jmir.org), 05.12.2018.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on http://mental.jmir.org/.as well as this copyright and license information must be included.

                History
                : 5 June 2018
                : 9 July 2018
                : 27 July 2018
                : 2 August 2018
                Categories
                Original Paper
                Original Paper

                inclusive design,user-centered design,participatory design,design thinking,mhealth,ehealth,digital therapy,schizophrenia,paranoia,psychosis

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