This study attempted to examine the validity and feasibility of a self-report scale for assessing psychotic symptoms on appropriately enabled mobile phones. The results suggest that the methodology is both feasible and acceptable across different stages of psychosis. Additionally, the data support the validity and reliability of several of the momentary items, suggesting that they pose a useful alternative to traditional symptom assessment.
The number of individuals dropping out of the study was relatively low across remitted and UHR samples, although slightly elevated in acute patients, where a third of individuals were non-compliant. This may explain the finding that positive symptoms significantly predicted non-compliance to the procedure. This supports the notion that momentary assessment is a relatively demanding approach, to which certain more symptomatic and chaotic patients may have difficulty in remaining compliant [21
]. Thus, in acute settings it may be beneficial to adapt the momentary assessment procedure (e.g. sampling rate, item number) to individual’s preferences and needs, or use an alternative method of assessment.
In compliant individuals, the number of assessment occasions was relatively high and similar to past momentary assessment research using PDAs in this population. For example, Swendsen and colleagues [15
] observed an identical completion rate of 72% of all data-point completed, whereas Granholm and colleagues [13
] found this to be 69%. In our study the number of entries was non-significantly different between the groups, suggesting that although a subgroup of acute patients struggled to complete the minimum number of entries, the majority were just as able to comply with the procedure as those with more attenuated symptoms. It should be noted that although compliance was high in this study rates of refusal to initially take part could not be assessed. Furthermore, socioeconomic status and reading ability were not considered, which may have predicted levels of non-compliance.
Reactivity to the methodology was minimal across the groups, although it was slightly elevated in individuals with greater levels of negative symptoms. This may explain why these symptoms have been found to predict drop-out in experience sampling studies (unpublished observation). Important to note is that reactivity could not be assessed in individuals who dropped out of this study and did not complete any diary entries. It is possible that greater levels of reactivity may be observed in non-compliant participants.
In line with the hypotheses, correlations with PANSS and CDS subscales were mainly significant, although there was considerable variability. Positive symptom scales (i.e. delusions, hallucinations, grandiosity, somatic concern and suspiciousness) generally showed moderate to strong correlations with their corresponding PANSS scales. Affective symptoms, including hopelessness, anxiety, guilt and depression, also significantly correlated with the interview measures. Therefore, ClinTouch appears to collect data which is comparable to traditionally used, gold standard assessments of psychotic symptoms and mood.
Passive apathetic social withdrawal, excitement, hostility and cognitive disorganisation items showed weak and non-significant correlations with their corresponding interview scores, requiring further consideration. There are several possible reasons for this finding. Most important is that the equivalent PANSS item ratings are based largely on observable behaviour during the interview, often supplemented by the reports of clinical staff and family members. Replicating this in a self-report item is a challenge. This is not to say that either holds a more valid or clinically useful viewpoint, but rather that they assess different constructs. Also, hostility and excitement represent socially undesirable behaviours, which patients may not associate with themselves or may wish to underplay in self-report measures. Finally, there was a limited range of scores observed on the apathetic social withdrawal and cognitive disorganisation PANSS subscales, which may have attenuated the correlations with the momentary assessment scales.
All of the mobile phone self-report scales showed instability (ie fluctuations) across time as shown by high within subject MSSD
scores, suggesting that they were sensitive to subtle shifts in symptomatology. Indeed, the mood scales (i.e. anxiety, depression and guilt) showed equivalent or greater levels of instability than typically employed experience sampling scales [27
]. Delusions and grandiosity were the most stable across time potentially suggesting that these reflect relatively fixed and inflexible belief systems. Passive apathetic social withdrawal showed the greatest instability, perhaps representing changes in the individual’s inclination to be around others. All of the self-report scales also showed good internal consistency.
The advantages of using technology to monitor mental illness have recently been documented [28
]. Ambulant monitoring provides detailed information about an individual’s symptoms across a variety of situations and times of the day. This could generate discussion points for consultation; identify ‘relapse signatures’; and highlight momentary symptom triggers. It could also be used to monitor real-time acute phase medication treatment effects in the early stages of intervention [30
]. This is important given that most clinical improvement is now known to occur within the first 7-days after receiving antipsychotic treatment [31
]. Furthermore, mobile assessment techniques can be adapted for use alongside psychosocial intervention [33
]. For example, person-tailored interventions could be triggered when an individual’s symptom score reaches a certain threshold or to facilitate ‘homework’ [34
]. In research, it will also potentially allow better clinical phenotyping, and stratification for clinical trials.
Perhaps the greatest strengths of ClinTouch are that it offers automatic wireless uploading of clinical information to a central server and can be installed on patients’ own phones, thus obviating the need to carry a special purpose device. Furthermore, smartphone technology may be more user-friendly and time-efficient than text-based systems [35
]. We observed that the majority of this sample currently owned and regularly used mobile phone technology, many of which were smart phones. With advances in technology it is likely that advanced mobile phones will become increasingly affordable and widespread, and this will make it a viable option for clinical assessment within clinical services. Future research will need to evaluate the merits and pitfalls of this approach.
Previous research in the area of telehealth and telecare devises suggests a need for deeper understanding of how ClinTouch is used in practice to identify the factors that facilitate implementation of this device. As the field of new technology in mental health aspires to moves beyond demonstration and towards the embedding of devices such as ClinTouch in everyday clinical practice, there is a need to engage methods and sub-studies that are able to describe the processes, identifying facilitators to context specific and successful implementation of telecare [36
]. Qualitative methods are being used to consider the social practices behind the integration and incorporation of the ClinTouch technology. Understanding their interactions with professionals and the synergy or otherwise with clinical expectations will inform its future use.