Smartphones for Smarter Care? Self-Management in Schizophrenia

The patient with schizophrenia described in this article sought out smartphone applications for which of the following reasons?

“Mr. A” is a 30-year-old orthodox Christian single man, originally from Eritrea, who has been diagnosed with schizophrenia. He lived in a refugee camp for 9 months before arriving in the United States. Five months after his arrival, Mr. A started to feel “irritable, aggressive, disoriented, and confused.” Shortly thereafter, he experienced his first psychotic break. As a consequence, he could not retain his job, lost interest in school, and was asked to leave his relative’s house: in the Eritrean community, mental health problems are poorly understood and not well received. He was soon hospitalized for psychosis, the first of many experiences with the U.S. mental health care system. After his discharge, he discontinued his medication and psychotherapy sessions because he denied having a mental illness.

Beginning in his mid-20s, Mr. A had irritable mood, lack of sleep, constant interpersonal difficulties (not being able to understand the content and context of his social interactions), and psychotic symptoms (e.g., he was convinced that strangers on the street were talking disparagingly about him; voices persuaded him to travel from Boston to New York City, thinking that his symptoms would disappear if he moved to a different city). In his first year in the United States, Mr. A was hospitalized three times, precipitated by paranoia, fear of being attacked, and elevated mood. Mr. A attributed his relapse to his cultural and religious background: “Being mentally ill is taboo, it means that you are weak.” Further contributing to his relapse were medication nonadherence and side effects, including weight gain and obesity, which are also not accepted in his culture. A total of five medication attempts and 3 years of psychotherapy were required to stabilize him. Lack of social support, unstable housing, unstructured daily life, and intermittent psychotic symptoms led to homelessness until Mr. A was picked up by a local shelter in Boston. Four years ago, after another hospitalization, he was referred to a state outpatient clinic for ongoing psychiatric treatment, where he is currently treated.

Mr. A’s therapist helped him overcome his paranoia and connected him to resources, such as housing, food assistance, and other medical services. While attending therapy, he looked into additional services to supplement his quarterly appointments with his psychiatrist and his twice monthly psychotherapy sessions. Without discussion or consultation with his treatment team, he decided to explore mental health–related smartphone apps to see what they could offer him: “I was being creative in solving my problems, and I needed extra help with my counseling, so that’s why I chose to start with the apps store,” he explained. His app store search included keywords such as “counseling for schizophrenia” and “DBT [dialectical behavior therapy] for schizophrenia.” As he learned more about his symptoms, he used more specific search terms: emotional intelligence, facial reading, cognitive abilities (e.g., speed reading), and memory exercises. He downloaded several mobile apps based on their topics and online ratings.

Treatment as Usual

Before he started using smartphone apps, Mr. A was, for the most part, psychiatrically and emotionally stable. The emphasis in therapy was on working on cognitive-behavioral skills to manage symptoms; as a result, Mr. A became aware of his negative and positive symptoms as well as the importance of taking his medications. However, he reported that he could not move forward with his life because he needed to improve in areas that were not part of his psychiatric treatment; getting and maintaining a job, socializing with the community, and acting/reacting in ambiguous social situations were all areas in which Mr. A struggled despite therapy: “I need help to practice my social and emotional skills in scenarios related to my life circumstances,” he said. “I need someone to give me feedback about what I do in those cases.” Additionally, he felt that his therapy could benefit from more frequent sessions and clearer explanations about his condition and symptoms.

Smartphone Intervention

Mr. A turned to smartphone apps to help fill these gaps in his treatment. He most frequently utilized “DBT 911,” “Facial and Emotion Recognition,” and “Virtual Hope Box.” These apps provided education about his illness and helped him monitor his symptoms. He experimented briefly with 20 other apps, the names of which he does not recall. He also learned and practiced cognitive-behavioral skills, breathing relaxation techniques, social cue identification, and emotion regulation and recognition. The Facial and Emotion Recognition app, for instance, allowed him to practice reading facial expressions in people of different ages, ethnicities, races, and genders in a way that face-to-face therapy could not. DBT 911 helped Mr. A understand and identify his emotions, practice mindfulness, manage relationships, and develop distress tolerance skills in scenarios relevant to his recovery plan. Virtual Hope Box helped him customize, organize, and plan several coping strategies into a recovery agenda that he could use during the week or for specific situations. His customized intervention included scheduling positive thoughts, listening to music or watching videos as a distraction strategy, practicing guided imagery, and using controlled breathing.

Intervention by the therapist (L.R.S.) focused on detection of early signs of distress. This motivated Mr. A to search for apps that could complement and expand his sessions outside the clinical setting. Over time, Mr. A (in consultation with his therapist) created his own app-based treatment plan to supplement the one that was offered in the clinic. Mr. A’s main therapeutic goals were threefold: to manage paranoid thoughts, to cope with social and cultural stressors, and to improve cognition.

Mr. A began to understand his symptoms, to gain more insight and self-reflection, and to improve his adherence to clinic visits and medication. He became a proponent of his own treatment by suggesting treatment options in the same way a therapist would, and he empowered his experience as a patient by testing multiple technologies on himself and reporting his findings. The clinician provided a safe environment, fine-tuning of the intervention, and clinical expertise, listening, and the validation that a computer cannot offer. However, it was only with the help of apps that Mr. A was able to understand, learn, and practice cognitive-behavioral skills both to prevent relapses and to increase his functionality in the community.

C. Supplemental counseling for schizophrenia

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