A Smartphone Intervention for People With Serious Mental Illness: Fully Remote Randomized Controlled Trial of CORE

Abstract

Background: People with serious mental illness (SMI) have significant unmet mental health needs. Development and testing of digital interventions that can alleviate the suffering of people with SMI is a public health priority.

Objective: The aim of this study is to conduct a fully remote randomized waitlist-controlled trial of CORE, a smartphone intervention that comprises daily exercises designed to promote reassessment of dysfunctional beliefs in multiple domains.

Methods: Individuals were recruited via the web using Google and Facebook advertisements. Enrolled participants were randomized into either active intervention or waitlist control groups. Participants completed the Beck Depression Inventory-Second Edition (BDI-II), Generalized Anxiety Disorder-7 (GAD-7), Hamilton Program for Schizophrenia Voices, Green Paranoid Thought Scale, Recovery Assessment Scale (RAS), Rosenberg Self-Esteem Scale (RSES), Friendship Scale, and Sheehan Disability Scale (SDS) at baseline (T1), 30-day (T2), and 60-day (T3) assessment points. Participants in the active group used CORE from T1 to T2, and participants in the waitlist group used CORE from T2 to T3. Both groups completed usability and accessibility measures after they concluded their intervention periods.

Results: Overall, 315 individuals from 45 states participated in this study. The sample comprised individuals with self-reported bipolar disorder (111/315, 35.2%), major depressive disorder (136/315, 43.2%), and schizophrenia or schizoaffective disorder (68/315, 21.6%) who displayed moderate to severe symptoms and disability levels at baseline. Participants rated CORE as highly usable and acceptable. Intent-to-treat analyses showed significant treatment×time interactions for the BDI-II (F1,313=13.38; P<.001), GAD-7 (F1,313=5.87; P=.01), RAS (F1,313=23.42; P<.001), RSES (F1,313=19.28; P<.001), and SDS (F1,313=10.73; P=.001). Large effects were observed for the BDI-II (d=0.58), RAS (d=0.61), and RSES (d=0.64); a moderate effect size was observed for the SDS (d=0.44), and a small effect size was observed for the GAD-7 (d=0.20). Similar changes in outcome measures were later observed in the waitlist control group participants following crossover after they received CORE (T2 to T3). Approximately 41.5% (64/154) of participants in the active group and 60.2% (97/161) of participants in the waitlist group were retained at T2, and 33.1% (51/154) of participants in the active group and 40.3% (65/161) of participants in the waitlist group were retained at T3.

Conclusions: We successfully recruited, screened, randomized, treated, and assessed a geographically dispersed sample of participants with SMI entirely via the web, demonstrating that fully remote clinical trials are feasible in this population; however, study retention remains challenging. CORE showed promise as a usable, acceptable, and effective tool for reducing the severity of psychiatric symptoms and disability while improving recovery and self-esteem. Rapid adoption and real-world dissemination of evidence-based mobile health interventions such as CORE are needed if we are to shorten the science-to-service gap and address the significant unmet mental health needs of people with SMI during the COVID-19 pandemic and beyond.

Trial registration: ClinicalTrials.gov NCT04068467; https://ichgcp.net/clinical-trials-registry/NCT04068467.

Keywords: bipolar disorder; depression; mobile health; mobile phone; schizophrenia.

Conflict of interest statement

Conflicts of Interest: DBZ has an intervention content licensing agreement with Pear Therapeutics and has a financial interest in Merlin LLC and FOCUS technology. He has consulted with Trusst Health, K Health, eQuility, and Otsuka Pharmaceuticals Ltd. GD is the cofounder of GGtude Ltd and has a financial interest in the CORE app described in this paper. Data analyses were conducted by members of the team who were unaffiliated with GGtude Ltd. All the remaining authors have no conflicts of interest to declare.

©Dror Ben-Zeev, Ayesha Chander, Justin Tauscher, Benjamin Buck, Subigya Nepal, Andrew Campbell, Guy Doron. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 12.11.2021.

Figures

Figure 1

Screenshots of the (a) targeted beliefs menu, (b) an example of a maladaptive statement, and (c) a psychoeducational element.

Figure 2

CONSORT (Consolidated Standards of Reporting Trials) diagram.

Figure 3

Map of participants enrolled based on location.

Figure 4

Outcome measures (y-axis) at baseline (T1), 30 days (T2), and 60 days (T3) assessments points (x-axis) for active group and waitlist control group. BDI-II: Beck Depression Inventory-Second Edition; GAD-7: Generalized Anxiety Disorder-7; GPTS: Green Paranoid Thought Scale; HPSVQ: Hamilton Program for Schizophrenia Voices; RAS: Recovery Assessment Scale; RSES: Rosenberg Self-esteem Scale; SDS: Sheehan Disability Scale.