4.3 ENHANCING SOCIAL FUNCTIONING AND LONG-TERM RECOVERY IN YOUNG PEOPLE WITH FIRST EPISODE PSYCHOSIS (FEP) AND YOUNG PEOPLE AT ULTRA HIGH RISK (UHR) FOR PSYCHOSIS: A NOVEL ONLINE SOCIAL THERAPY APPROACH

Abstract Background Specialized early intervention services have demonstrated improved outcomes in first episode psychosis (FEP); however, functional recovery lags behind symptomatic remission, and many FEP patients remain socially isolated with poor functional outcomes. Similarly, psychological and pharmacological treatments have been demonstrated to reduce rates of transition to psychosis in Ultra High Risk (UHR) patients. However, recent research shows that UHR patients have a poor functional outcome regardless of transition to psychosis. These findings have resulted in widespread calls for new treatments aimed at improving functioning in both FEP and UHR patients. The aim of these studies was to determine the safety, acceptability, feasibility and treatment effects of an advanced online social media based intervention specifically designed to enhance social functioning in FEP and UHR patients. Methods Our multi-disciplinary team of 35 researchers, software engineers, professional writers, clinical psychologists, comic developers, experts in human-computer interaction and young people has developed novel online social media platforms for young people with FEP (Horyzons), and UHR patients (Momentum). Our interventions integrate: i) peer-to-peer social networking, ii) tailored therapeutic interventions, iii) expert and peer-moderation, and iv) new models of psychological therapy (strengths-based models, self-compassion and mindfulness). The acceptability and safety of these platforms have been evaluated through 2 pilot studies in FEP (N=20; 1 month intervention), and UHR (N=15; 2 months intervention). In addition, the effectiveness of Horyzons is currently being evaluated in a large 5 year RCT in FEP (N=170; 18 months intervention). Results UHR pilot: System usage was high, with a total 270 logins (18/user), 749 posts (58/user), 170 therapy modules completed (12/user), and 67% of users being actively engaged over the trial. All participants reported a positive experience using Momentum and would recommend it to others. 93% considered Momentum to be helpful. Analysis revealed a significant increase in social functioning (p<0.001; d=2.39) and satisfaction with life (p=0.03; d=0.48) at follow-up. There was a significant increase in therapy mechanisms directly targeted by Momentum including strengths usage (p=0.03; d=0.46), mindfulness skills (p=0.04; d=0.36) and components of social support. There were significant correlations between system usage and improvements in social functioning (r=0.63 p=0.02), social support (r=0.62 p=0.02) and strengths usage (r=0.51 p=0.06). FEP pilot: system use was high. The majority of FEP participants reported feeling safe (100%) and more socially connected (60%) using Horyzons. There was a significant reduction (d=0.60; p=0.03) in depressive symptoms at follow-up. FEP RCT: Horyzons’ safety outcomes have been consistently strong. System usage is being high, with an average 101 logins, 70 posts, and 11 therapy modules per user, and 60% of users being engaged with the online system for a period of 18 months. Discussion Horyzons and Momentum are the first online interventions designed to improve functional outcomes in FEP and UHR patients. Momentum is engaging, safe, may improve social functioning and satisfaction with life in UHR patients and appeared to specifically improve therapeutic mechanisms directly targeted by the online intervention. Horyzons is safe and engaging (over prolonged periods of time) and may improve depression and social connectedness in FEP patients.

care for 5 months and filled out satisfaction surveys at study-end regarding usability of the platform. Rate of survey completion in the absence of financial incentives was examined to determine real-world implementation of the platform. Results: For study 1, 76 clients enrolled and remained in the study for an average of 183 days (SD=88). Survey completion rates remained high over the course of the study (weekly surveys: 77%; daily surveys: 69%) and were not significantly impacted by baseline symptom severity or length of time in the study. Weekly survey positive and depression/anxiety symptoms were significantly associated with BPRS positive (p<0.001) and BPRS depression/anxiety symptoms (p< 0.001) respectively. EP clients reported high satisfaction with the platform and endorsed continue use of the app if it was made available as part of their treatment. For Study 2, 61 EP clients and 20 clinicians enrolled; 41 EP clients and 20 clinicians participated for 5 months. The majority of EP clients (66%) and clinicians (85%) who completed satisfaction surveys reported a desire to continue to use the platform as part of care. Six (15%) clients and 3 providers (23%) stated that technological glitches impeded their use of the platform. Discussion: These data support the validity and acceptability of implementing smartphone-based assessment of symptoms in community-based EP care. Specifically, results indicate that assessing positive and depression/ anxiety symptoms using weekly self-report surveys via smartphone is comparable to gold-standard clinician-led assessments. This approach may be a valid method of monitoring fluctuations in positive and depression/anxiety symptoms in EP populations to anticipate symptom exacerbations. However, solutions to logistical barriers such as technical challenges and clinician engagement with technology are necessary for widespread adoption across EP care. Background: Reducing the duration of untreated psychosis (DUP) is essential to improve long-term outcome in young people with first episode of psychosis (FEP). The US "standard of FEP care" focuses on targeted provider education regarding FEP signs and symptoms to motivate referrals to FEP coordinated specialty care (CSC) services. However, a recent US multisite CSC trial showed a median DUP of 74.5 weeks, suggesting the current approach to engage referral sources is not sufficient to reduce DUP to proposed international standards of 12 weeks. This cluster-randomized controlled trial assesses whether standard targeted provider education plus novel technology-enhanced screening using the Prodromal Questionnaire-Brief version (PQ-B) identifies more individuals with FEP, earlier in their illness, compared to standard targeted provider education alone. Methods: Twenty-two sites were randomized within 3 strata [community mental health, CMH (N=10), middle/high schools, SCH (N=8), primary care, PC (N=4)] to 1 of 2 intervention arms [Education alone (TAU) vs Education + Electronic Screening (Active)]. Active sites screened eligible individuals ages 12-30 at initial presentation for mental health concerns and referred those who passed a liberal PQ-B cut off score for phone evaluation by the CSC clinic. TAU sites referred individuals for phone evaluation based on clinician judgment. Phone evaluations assessed eligibility for FEP services and DUP. Preliminary analyses examined the number of FEP referrals and length of DUP in each arm.

A TECHNOLOGY-ENHANCED
Results: Active sites effectively implemented electronic screening within their settings. Of the 822 individuals electronically screened at Active sites between June 2015 and July 2017, 43.2% scored above the PQ-B cutoff (mean±SD PQ-B score=21.25 ± 20.75; median=15; range = 0-95; IQR = 3-35). One in 8 individuals who completed the tablet were identified as experiencing threshold psychosis. Across both Active and TAU sites, 511 individuals were identified, 422 individuals agreed to be referred, and 319 completed a phone interview to determine eligibility: 33.23% reported attenuated and 36.68% fully psychotic symptoms. Active sites identified significantly more individuals with threshold psychosis (p<.001) than TAU. No difference in median days of DUP was observed across arms. Discussion: Preliminary results show the feasibility of electronic screening across various community settings and showed a 3.5 times higher identification rate for electronic screening of self-reported psychosis spectrum symptoms than clinician-based identification alone. Reasons for the lack of difference in DUP will be discussed. While the screening method may shorten the time from entry into mental health care and referral to specialty care treatment, significant DUP reduction may require interventions to reduce time to the first mental health contact. The next phase of the project will examine impact of clinic-based versus community-based treatment engagement to reduce barriers to initiating CSC care. Background: Specialized early intervention services have demonstrated improved outcomes in first episode psychosis (FEP); however, functional recovery lags behind symptomatic remission, and many FEP patients remain socially isolated with poor functional outcomes. Similarly, psychological and pharmacological treatments have been demonstrated to reduce rates of transition to psychosis in Ultra High Risk (UHR) patients. However, recent research shows that UHR patients have a poor functional outcome regardless of transition to psychosis. These findings have resulted in widespread calls for new treatments aimed at improving functioning in both FEP and UHR patients. The aim of these studies was to determine the safety, acceptability, feasibility and treatment effects of an advanced online social media based intervention specifically designed to enhance social functioning in FEP and UHR patients. Methods: Our multi-disciplinary team of 35 researchers, software engineers, professional writers, clinical psychologists, comic developers, experts in human-computer interaction and young people has developed novel online social media platforms for young people with FEP (Horyzons), and UHR patients (Momentum). Our interventions integrate: i) peer-to-peer social networking, ii) tailored therapeutic interventions, iii) expert and peermoderation, and iv) new models of psychological therapy (strengths-based models, self-compassion and mindfulness). The acceptability and safety of these platforms have been evaluated through 2 pilot studies in FEP (N=20; 1 month intervention), and UHR (N=15; 2 months intervention). In addition, the effectiveness of Horyzons is currently being evaluated in a large 5 year RCT in FEP (N=170; 18 months intervention).

ENHANCING SOCIAL FUNCTIONING AND
Results: UHR pilot: System usage was high, with a total 270 logins (18/ user), 749 posts (58/user), 170 therapy modules completed (12/user), and 67% of users being actively engaged over the trial. All participants reported a positive experience using Momentum and would recommend it to others. 93% considered Momentum to be helpful. Analysis revealed a significant increase in social functioning (p<0.001; d=2.39) and satisfaction with life (p=0.03; d=0.48) at follow-up. There was a significant increase in therapy mechanisms directly targeted by Momentum including strengths usage (p=0.03; d=0.46), mindfulness skills (p=0.04; d=0.36) and components of social support. There were significant correlations between system usage and improvements in social functioning (r=0.63 p=0.02), social support (r=0.62 p=0.02) and strengths usage (r=0.51 p=0.06). FEP pilot: system use was high. The majority of FEP participants reported feeling safe (100%) and more socially connected (60%) using Horyzons. There was a significant reduction (d=0.60; p=0.03) in depressive symptoms at follow-up. FEP RCT: Horyzons' safety outcomes have been consistently strong. System usage is being high, with an average 101 logins, 70 posts, and 11 therapy modules per user, and 60% of users being engaged with the online system for a period of 18 months. Discussion: Horyzons and Momentum are the first online interventions designed to improve functional outcomes in FEP and UHR patients. Momentum is engaging, safe, may improve social functioning and satisfaction with life in UHR patients and appeared to specifically improve therapeutic mechanisms directly targeted by the online intervention. Horyzons is safe and engaging (over prolonged periods of time) and may improve depression and social connectedness in FEP patients. Background: Adjunctive psychological interventions as an add-on to pharmacological treatment in serious mental illnesses have shown to further improve long-term outcome, especially in the case of Bipolar Disorder and first episode psychosis. Among them, psychoeducational programs have a well-established evidence of efficacy and cost-efficiency. However, there are several limitations restricting the broad implementation of these psychological treatments, out of which the most important one is related to a tremendous gap between availability and demand. Therefore, there is an emerging interest to explore new approaches to deliver this kind of treatments tailored to individual needs and in a continuous way (e.g. all year long) from any location while maintaining their efficacy at a low cost. The high availability of Internet connected devices as well as it's user-friendly interfaces could be a potential and feasible window to expand and extend psychoeducational programs in Bipolar disorder and other serious mental illnesses. The main objective of this presentation will be: 1. to review the available internet-based psychological interventions for bipolar disorder, 2. to present the SIMPLe project development, studies protocols, results from a feasibility study and an open study, and finally, 3. to provide some insights and perspectives into the future of the field. Methods: A systematic-review of the literature was undertook to review the available internet-based psychological interventions for bipolar disorder and provide a critical appraisal of the studies and platforms included. A feasibility pilot study was conducted to test the first version of the SIMPLe app in which retention, acceptability and satisfaction were assessed in a group of subsequent samples of bipolar patients using the app, pre and post intervention questionnaires and assessments were conducted during face to face interviews. Regarding the open trial (i.e. OpenSIMPLe), a similar approach was adopted, but involving patients from all around the world and using online questionnaires. Results: During the systematic review we identified over 251 potential entries matching the search criteria and after a thorough manual review, 29 publications pertaining to 12 different projects, specifically focusing on psychological interventions for bipolar patients through diverse Internet-based methods, were selected. In the feasibility study, 51 participants were initially enrolled in the study, 36 (74%) remained actively using the application after 3 months. The whole sample interacted with the application a mean of 77 days (SD=26.2). Over 86% of the participants agreed that the experience using the application was satisfactory. So far, the OpenSIMPLe trial have enrolled more than 300 participants, preliminary results show levels of satisfaction beyond 80%, although a retention of only 5% after 6 months was calculated from servers registries. Discussion: Considering the high rates of retention and compliance reported, they represent a potential highly feasible and acceptable method of delivering this kind of interventions to bipolar patients. The results of the feasibility study confirms that this particular intervention is feasible and represent a satisfactory and acceptable instrument for the self-management of bipolar disorder as an add-on to the usual treatment but future clinical trials must still probe its efficacy. Moreover, preliminary results from the OpenSIMPLe study shows that is feasible to extend this intervention to many people at a low cost. Present and future technologies employing passive data collection and weareables could improve the personalization and accuracy of these interventions.

INTERNET-BASED INTERVENTIONS FOR BIPOLAR DISORDER
5. RETHINKING THE TAXONOMY, COURSE, AND OUTCOME OF PSYCHOSES: DIMENSIONAL, LATENT TRAJECTORY, AND TRANSDIAGNOSTIC APPROACHES William T. Carpenter, Jr.

University of Maryland School of Medicine
Overall Abstract: Evidence continues to accumulate on heterogeneity in phenomenology, course and outcome of non-affective and affective psychotic disorders. Both DSM and ICD classification systems have evolved to include a large number of categories of psychosis. However, doubt remains about this categorical approach because of high comorbidity, common etiological factors and the absence of zones of relative rarity between categorical diagnoses. Some authors have nevertheless argued that categorical representations of psychosis may still be of clinical utility if used in combination with dimensional indicators. It is now widely accepted that psychotic symptoms partition into several symptom dimensions that would support the heterogeneity of psychotic disorders. However, there is no consensus on the exact number of these dimensions, with previous factor-analytic work pointing towards models with two to twelve specific symptom dimensions. However, recently, there has been evidence for a transdiagnostic dimension underlying affective and non-affective psychotic symptoms in schizophrenia, schizoaffective and bipolar disorder that challenges their classification as distinct diagnostic constructs. There is also considerable heterogeneity in clinical course and outcome of psychotic disorders, but how to best map and model this over time remains to be established. Taken together, this presents significant challenges for the classification of psychotic disorders as separate diagnostic entities. This symposium brings together international researchers at the forefront of research into the phenomenology, course and outcome of psychotic disorders. Roman Kotov will present novel data on symptom dimensions and examines the course of these dimensions in an epidemiologic cohort of 628 first-admission inpatients with psychosis interviewed 6 times over two decades in the Suffolk County Mental Health Project. Craig Morgan will report new findings from the 10-year follow-up of the Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP-10) study, an epidemiological cohort of 552 patients with a first episode psychosis, using a data driven