# This is the FOCUS team Dror Ben-Zeev, Christopher J. Brenner, Mark Begale, Jennifer Duffecy, David C. Mohr, and Kim T. Mueser 1Department of Psychiatry, Dartmouth Psychiatric Research Center, Geisel School of Medicine at Dartmouth, Lebanon, NH; 2Thresholds, Chicago, IL; 3Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University, Chicago, IL; 4Center for Psychiatric Rehabilitation, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA - The paper - [[Feasibility, Acceptability, and Preliminary Efficacy of a Smartphone Intervention for Schizophrenia.pdf]] - Qualitative Research about FOCUS - [[Life With FOCUS A Qualitative Evaluation of the Impact of a Smartphone Intervention on People With Serious Mental Illness]] - [[Article - Transdiagnostic Mobile Health - smartphone Intervention Reduces Depressive Symptoms in People With Mood and Psychotic Disorders]] # Key Summary for me: 1. 33 People. Average age 45.9. Follow up for 1 month. They use this app that send patient EMA. (3 times a day. 9-1pm, 1-5pm, 5-9pm) 2. The app ask "Can you check in with FOCUS right now?" If yes, it open up to a page that display "Medication" "Voices" "Mood" "Social" "Sleep" - Paper did not describe how exactly the screen flows, and what kind of EMI was given. 3. Staff check in weekly. 4. Actually not very smart - compare to HOPES. We have Passive Data tracking and Clinicians Logic that is predictive. FOCUS is not predictive. Their Onboarding Process - Patient can select a treatment targets they want to work on, - content different? - Medication Adherence (Constant) - Social (Include targeting persecutory ideation, anger management, social skills training) - Mood Problems - Auditory Hallucinations - Sleep Difficulties Clinical Measures - Demographic - Average Life time Hospitalisation - PNSS - Beck Depression Inventory - Insomnia - Brief Medication Questionnaire - Brief Assessment of Cognition in Schizophrenia Feasibility - Based on how much the user use the app. - - On average, these participants used the FOCUS system on 86.5% of the days they had the smartphone (week 1 average: 6.7 days, week 4 average: 5.9 days). On days FOCUS was used, participants interacted with the system an average of 5.19 times (week 1 average: 6.4 times daily, week 4 average: 4.9 times daily). Participants initiated their interactions with FOCUS on 62.5% of the times it was used (ie, using on-demand interventions) and 37.5% of use was in response to prescheduled system prompts. ^f96478 Acceptability/Usability - 26 Item Self-reported Acceptability/Usability Measure adapted from - System Usability Scale,38 Post Study System Usability Questionnaire,39 Technology Assessment Model Measurement Scales,40 and Usefulness, Satisfaction, and Ease questionnaire.41 Participants were asked to rate their agreement with a series of statements about the intervention ![[Screenshot 2022-12-23 at 11.34.22 AM.png]] ^54bc46 Result - Based on one month of usage. It is helpful in reduction of PANSS and general symptoms of psychopathology, and depression. - We found a significant association between the change in participants’ BDI-2 scores and the percentage of days participants used FOCUS over the 1-month period (r = −.36, P < .05); the greater the reduction in depressive symptoms, the less often participants used the system. There was no significant association between PANSS scores and the percentage of days participants used the system. ^66721c ### Conceptual framework for the intervention #Conceptual_Framework The FOCUS system is grounded in two theoretical models: the #cognitive_model of psychosis and the #stress_vulnerability_model of schizophrenia. The cognitive model of psychosis ([Freeman, Garety, Kuipers, Fowler, & Bebbington, 2002](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4357360/#R10); [Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4357360/#R12)) proposes that, in the context of illness-related neurobiological vulnerabilities, maladaptive thinking styles (e.g., a tendency to “jump to conclusions,” cognitive inflexibility) and distorted schemas about the self (e.g., I am incompetent, I am bad), others (e.g., people are hostile), and the world (e.g., the world is dangerous) contribute to the emergence of firmly held dysfunctional beliefs (e.g., delusions of persecution, reference, control) and fuel the interpretation of anomalous sensory experiences (e.g., auditory hallucinations with derogatory content). The model emphasizes the important role of social interactions and suggests social isolation is especially detrimental, as it contributes to sustainment of dysfunctional beliefs that go unchecked and unchallenged over time. It also suggests distress and dysfunction associated with experiencing symptoms are largely linked to the meaning and interpretation of symptoms (e.g., voices are of divine origin) and beliefs regarding anticipated consequences (e.g., I will never be able to work). The stress-vulnerability model ([Liberman et al., 1986](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4357360/#R17); [Zubin & Spring, 1977](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4357360/#R38)) posits that the course and outcomes of schizophrenia are determined by the interplay of biological vulnerabilities (e.g., predisposition for the illness), stress, and coping. To improve illness outcomes, illness-management strategies for schizophrenia based on this model aim to interrupt the cyclical relationship between stress (e.g., fatigue, interpersonal conflict, poor medication adherence) and vulnerability that often lead to symptomatic relapse and illness exacerbation ([Mueser et al., 2006](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4357360/#R24)). The FOCUS system is composed of several applications that deploy an array of adapted psychosocial intervention techniques targeting five general domains: #medication_adherence (behavioral tailoring, psychoeducation about illness, and motivational interviewing strategies), #mood_regulation (behavioral activation for depression, mindfulness and relaxation strategies for anxiety), #sleep (sleep hygiene strategies, health and wellness psychoeducation), social functioning (anger management, activity scheduling, and cognitive restructuring for persecutory ideation) #socialization , and coping with persistent auditory hallucinations #auditory_hallucinations (distraction, relaxation, guided hypothesis testing). Our intention was to structure an intervention framework that would allow users to select the areas they would like to focus on from a menu that could be populated with additional content and treatment targets in the future with relative ease (e.g., diabetes management, smoking cessation). ^65ee57 System comprised of 3 Apps 1. Prompt user daily 1. How has your mood been today? > Very bad, I am very upset. > Look like you could use some support, FOCUS is happy to help. > Have you had any of these thoughts lately? > EMI >Thank you 2. Algorithm general EMI 3. Resource Quick Tip - self-management