Reeva Lederman

On the HORYZON: Moderated online social therapy for long-term recovery in first episode psychosis

BACKGROUND Early intervention services have demonstrated improved outcomes in first episode psychosis (FEP); however, recent evidence shows that treatment benefits may not be sustainable over time. These findings have resulted in repeated recommendations for the implementation of longer term treatment programs. An Internet-based intervention specifically designed for young people with psychosis may provide a cost-effective alternative to prevent loss of treatment benefits from early intervention. METHODS Our multi-disciplinary team has developed a highly novel online intervention (HORYZONS) in regular consultation with stakeholders within a specialist early psychosis program. HORYZONS integrates: i) peer-to-peer social networking, ii) individually tailored interactive psychosocial interventions, and iii) expert interdisciplinary and peer-moderation in a coherent platform designed to improve long-term outcomes in FEP. The acceptability, safety and initial clinical benefits of HORYZONS were examined through a 1-month pilot study with 20 participants with FEP. RESULTS There were no dropouts during the pilot study. Seventy per cent of participants utilised the system for at least 3weeks, 95% used the social networking features, and 60% completed at least 3 therapy modules. System usage was high during the study. There were no incidents and the majority of participants reported feeling safe, empowered and more socially connected using HORYZONS. Analysis revealed a significant reduction in depressive symptoms at follow-up. CONCLUSIONS Our results indicate that HORYZONS is feasible, engaging and safe and may augment social connectedness and empowerment in FEP. These findings have significant implications for the enhancement of specialist FEP services. The potential of HORYZONS to improve long-term recovery is worthy of further investigation.

Moderated online social therapy: Designing and evaluating technology for mental health

Although the use and prevalence of Web-based mental health applications have grown over the past decade, many of these services suffer high rates of attrition. This is problematic, as face-to-face support for mental health is limited. To determine appropriate design guidelines for increasing engagement, we conducted a study of First-Episode Psychosis (FEP) patients and reviewed theories on the use of existing online services. We produced a set of design goals, developed an online application that combined social networking and online therapy within a clinician-moderated site, and conducted a 6-week trial with a group of young FEP patients. The design goals, based on existing theory including Supportive Accountability and Positive Psychology, are operationlised through a model we call Moderated Online Social Therapy (MOST). The trial results indicate that our implementation achieved the design goals and that the MOST model can inform the development of more effective and engaging online therapies.

Internet-based interventions for psychosis: a sneak-peek into the future.

The Internet and mobile technologies are becoming ubiquitous. However, the potential of these technologies to support people with psychosis has been unexplored and the development of innovative e-based interventions is overdue. Research suggests the acceptability and effectiveness of such interventions in psychosis. Internet-based technologies have the potential to transform psychosis treatment by enhancing the accessibility of evidence-based interventions, fostering engagement with mental health services, and maintaining treatment benefits over the long term. This article reviews the current evidence on Internet-based interventions for psychosis, including potential benefits, risks, and future challenges. Recommendations are proposed for developing future online interventions for psychosis.

A balanced evaluation perspective: picture archiving and communication system impacts on hospital workflow.

Around the world, hospitals are faced with both budget and regulatory pressures, forcing them to re-examine the way clinical practice is carried out. Proposed technologies that provide workflow enhancements include Picture Archiving and Communications Systems (PACS); however, is PACS really effective in improving hospital workflow and the flow onto patient care, and how should this be evaluated? An acknowledged and successful approach for organizational evaluation is the Balanced Scorecard (BSC), providing the fundamental features for assessing organizations from various perspectives. In this research, the impact of PACS on the workflow of a large public hospital in Melbourne, Australia, is examined using an adapted version of the BSC. Empirically, this model was applied as an evaluation instrument through a series of in-depth interviews with PACS users. Results show that PACS did improve hospital workflow considerably and that the organizational alignment of PACS in hospitals is an important critical success factor.

Participatory design of an online therapy for youth mental health

Online therapy has the potential to extend existing face-to-face support for mental health, but designers face challenges such as lack of user engagement. Participatory design could improve outcomes but is difficult to pursue in the mental health context. By working with a research-focused clinic we have been able to employ participatory design methods over a period of three years to develop and test an online therapy for young people with psychosis. This paper discusses our methods and results in the light of existing design frameworks for youth mental health, and reports experiences which will be useful for other researchers in the field. We have found that participatory approaches are indeed challenging in the mental health context, but can result in technology that is efficacious and acceptable to young people.

Systems failure in hospitals: using reason's model to predict problems in a prescribing information system

AbstractBoth hospitals and hospital patients are bearing a massive cost as a result of the occurrence of medication prescribing errors in the public health system (Bates, D., et al. J. Am. Med. Inform. Assoc. 8(4):299–308, 2001; Lombardi, T. Medscape Pharm. Online J. 02(1), 2001; Roberts, M., and Stokes, J. eMed. J. Aust. 168:317–318, 1998). Consequently, it is important to examine and address the possible causes of this problem. In this paper we suggest that poor information systems may be a contributing factor in the occurrence of these errors. We research this issue in an HIV ward of a large public hospital through interviews and a survey instrument. We find that in a significant number of instances prescribing errors are linked to situations where information is unavailable or inaccessible. This link, between problems in information delivery and prescribing errors, is a link whose extent has not been measured previously. It is, however, a link which exposes all stakeholders in the hospital system, the patient, the clinicians, the hospital, and governments funding prescription medications, to possible loss and damage and indicates a need for the implementation of more effective systems in this area. We use Reason’s model for predicting systems error (Vincent, C. BMJ 316:1154–1157, 1998) as a tool to suggest that prescribing errors have an increased likelihood of occurring if one or more of the types of failure identified in the model are present in the existing prescribing information delivery process in the hospital. While Reason’s model has been applied in a medical context, it has not been previously applied to errors which result from information systems failure. We feel that applying it in this way may shed some light on the causes of prescribing error.

Moderated online social therapy for depression relapse prevention in young people: pilot study of a ‘next generation’ online intervention

Implementation of targeted e‐mental health interventions offers a promising solution to reducing the burden of disease associated with youth depression. A single‐group pilot study was conducted to evaluate the acceptability, feasibility, usability and safety of a novel, moderated online social therapy intervention (entitled Rebound) for depression relapse prevention in young people.

Moderated Online Social Therapy for Recovery From Early Psychosis

Psychotic disorders are among the most distressing and disabling of psychiatric conditions. Their onset, characteristically in late adolescence when young people face significant developmental challenges, poses a significant risk of lifelong disability and compromised mental and physical health. Recurrent psychotic episodes, poor physical health, long-term unemployment, social anxiety, substance abuse, chronic depression, and even suicide are causes for concern after first-episode psychosis. Over the preceding 20 years, specialist early psychosis programs have evolved internationally in order to provide a more timely treatment and to support young people in achieving symptomatic remission and eventual full recovery. However, there are considerable challenges to achieving these aims. First, despite research showing that 90% of patients who receive treatment achieve good short-term symptomatic outcomes, a majority remain at risk of recurrence of acute symptoms. These relapses can lead to ongoing, chronic psychosis. Second, patients with a first episode of psychosis are at risk of experiencing secondary illnesses, including depression, anxiety, and compromised physical health as a result of rapid and pronounced weight gain and related metabolic disturbances. Third, although most young patients with first-episode psychosis participate over the short term in effective psychosocial and biological treatment programs, continuing with treatment and maintaining early gains is a major challenge for the field. For example, at the Early Psychosis Prevention and Intervention Centre, a specialist service for treating early psychosis, we developed an effective cognitive-behavioral therapy–based program for the prevention of relapse among first-episode patients who had reached remission of positive symptoms for a period of one month. The program showed significant benefits compared with specialist early psychosis treatment alone in terms of relapse rates over the first 12 months, but treatment effects were lost by the 18-month follow-up. Members of our group have also developed and evaluated a program for the prevention of weight gain associated with first-episode psychosis, which had a similar early, but unsustained pattern of results. Taken together, these results highlight the need to maintain effective psychosocial interventions over the long term after the onset of first-episode psychosis. However, even though five years is considered optimal, specialist early psychosis programs typically have treatment resources to support only 18 months to two years of follow-up. So clearly, novel, cost-effective, and youth-friendly strategies are required to address these problems in order to optimize the recovery of young people after their first episode of psychosis. One strategy our team has been working on is the utilization of information and communication technology (ICT), which has already frequently been applied to the treatment of depression, anxiety, and other mental health conditions. These Internetbased therapies have typically facilitated the interaction of a single user with an automated education program. Online discussion forums have also proliferated, but these generally lack evidence-based therapeutic content. Despite high rates of access to the Internet among young people, the application of online therapies to treat early psychosis has been extremely limited. We have formulated a new model of providing online interventions for first-episode psychosis and built a Web-based intervention informed by the model. Called the moderated online social therapy model, our ICT model has been developed by a multidisciplinary team of clinical psychologists, a computer programmer, a health informatics expert, a Web designer, a writer, and a graphic designer. The site has been built and was pilottested in March in consultation with young people with diagnosed psychosis, clinicians, and young computer users. Full testing is planned for 2013. The Web site integrates therapy modules (our “coach menu”) with a private moderated social networking function (our “cafe menu”). The modules begin with an interactive welcome segment. Subsequent interactive modules address psychoeducation, relapse prevention, stigma and social anxiety, early warning signs of relapse, depression, and identification and use of personal strengths. The cafe functions include a personal profile page (which can be kept anonymous if the user prefers), a network (similar to a “friends” function in social networking), a group problem-solving function (based on traditional social problemsolving therapy in which participants can draw on ideas from other users to generate solutions to everyday problems faced in recovery), and discussion threads linked to the modules. A “wall” function organizes discussion threads into relevant themes such as “what works for me,” where clients share successful approaches. A separate moderator interface enables daily guidance of discussions, risk monitoring, and tracking patterns of use. We suspect that this will be both an effective relapse prevention tool as well as a highly appealing and intuitive structure for young people to engage with each other and with expert moderators. John F. M. Gleeson, M.Psych., Ph.D. Mario Alvarez-Jimenez, D.Clin.Psy., Ph.D. Reeva Lederman, M.I.S., Ph.D.

One hundred tasks an hour: An observational study of emergency department consultant activities

Objective: To determine work activity patterns undertaken by ED consultants.

Decision support or support for situated choice: lessons for system design from effective manual systems

In a number of organisational settings where work is highly skilled but substantially routine, certain entrenched manual systems have resisted digitisation. These systems include card-based systems in emergency despatch, the paper flight progress strips system used in air traffic control, the Kanban system and whiteboard systems used in hospital wards. Research to understand or replace these systems has frequently regarded them as decision support systems (DSS). We report here a detailed case study of a manual whiteboard-based bed allocation system in the ICU of a large general hospital, which shows that the support it provides for users’ action choices cannot be validly conceived as decision support. This system and other effective manual systems may be better understood as a ‘situated choice support system’ (SCSS). Whereas DSS provide actors with a model of the action environment in order to support reasoning about the consequences of alternative actions, SCSS provide actors with structured work environments that reduce possible actions and cue-providing information resources to support a reactive choice between these limited alternatives. The findings warn of the danger of uncritically applying the DSS design paradigm to supporting action choice in skilled routine work, and provide an alternative design theory, which can potentially inform new ICT-based designs.