Four digital health technologies were identified at scoping which met the selection criteria for this topic. One of the technologies, gameChangeVR was evaluated in NICE's early value assessment (EVA) on virtual reality technologies for treating agoraphobia or agoraphobic avoidance and so was not included in the decision problem for this EVA.
NICE has assessed 3 digital health technologies for managing symptoms of psychosis or preventing relapse. All the technologies are delivered or supported by a mental health professional trained in the technology. The criteria for including technologies in this assessment are in the final scope for this guidance on the NICE website. The technologies are:
AVATAR Therapy for managing distressing auditory verbal hallucinations (hearing voices). It allows people to create a digital representation (an avatar) of their distressing voice. Over 6 to 12 sessions, the person is encouraged to engage in dialogue with this avatar to take power and control within the conversation. The avatar is voiced by a mental health professional, trained in this technology. This allows a 3‑way conversation between the person hearing voices, the avatar and the mental health professional. AVATAR Therapy can be delivered as a standalone intervention by a trained mental health professional. It can also be used as a component of standard care psychological interventions such as cognitive behavioural therapy for psychosis (CBTp).
SlowMo for managing distressing thoughts and paranoia in people with psychosis. It is a blended digital therapy that helps people to be aware of symptoms of psychosis, fast thinking and reasoning, and helps slow down thoughts. It is delivered in 8 sessions by a mental health professional, who is trained in the use of this technology, and who can access modules and interactive features using the SlowMo web app. People using SlowMo can also synchronise the content to a mobile app on their smartphone, for them to use it outside of sessions. SlowMo can be delivered as a standalone intervention by a trained mental health professional. It can also be used as a component of standard care psychological interventions such as CBTp.
CareLoop for remote monitoring of symptoms of psychosis. It aims to prevent relapse by identifying worsening symptoms. People using it regularly record symptoms, thoughts and feelings in an app using questionnaires and journal entries. CareLoop includes an algorithm that aims to recognise worsening mental health and potential relapse. This information is shared with mental health professionals who can then provide early interventions to prevent relapse.
The scope for this early value assessment included a target population of people aged 14 and over with primary psychosis. Treatment and care for psychosis in people aged 18 and over is usually managed in community mental health services including early intervention in psychosis (EIP) services and community mental health teams. NICE's guideline on psychosis and schizophrenia in adults recommends that adults with a first episode or first presentation of psychosis should have an assessment and treatment in an EIP service. After 3 years of treatment in an EIP service, longer-term treatment and care are usually then provided by community mental health teams. NICE's guideline on psychosis and schizophrenia in children and young people recommends that children and young people who present for the first time with sustained psychosis symptoms should have an urgent referral to child and adolescent mental health services or an EIP service. Longer-term treatment and care may then be provided in primary care or secondary care. For adults, children, and young people, inpatient hospital care may be considered by care providers for acute episodes of psychosis.
People with psychosis should be offered oral antipsychotic medicine and psychological interventions including CBTp and family intervention. If a person's symptoms respond well to treatment and remain stable, they should be offered the option to return to primary care for further management. Monitoring for relapse prevention varies across NHS services. It usually involves regular follow-ups with a care coordinator and reviews with a psychiatrist. The clinical experts advised that there is no formal relapse prevention process. People may be at high risk of relapse if there are changes to their medicine or other parts of their treatment or support. If relapse is suspected, treatment should be provided in line with a person's crisis plan, and referral to secondary care may be considered.
Clinical and patient experts advised that access to CBTp varies and is limited for some people. Most adults with psychosis who are having treatment outside of EIP services do not have access to the psychological interventions recommended by NICE's guideline on psychosis and schizophrenia. Digital health technologies may increase access to care by offering a non-medicine intervention for managing symptoms of psychosis. Some technologies are designed to monitor symptoms and to help detect relapses earlier, so people could have treatment sooner. Digital health technologies would be used as an alternative or addition to standard care, which may include CBTp to manage other symptoms of psychosis not covered by the technology.
The comparator for digital health technologies for managing symptoms of psychosis (AVATAR Therapy and SlowMo) is CBTp. Other psychological interventions such as group therapy or supportive counselling may be offered instead for some people on waiting lists to have CBTp. In some areas, people on waiting lists may not be offered any psychological support. Clinical experts advised that digital health technologies would not be offered instead of antipsychotic medicine. So, this was not a comparator in this assessment.
The comparator for digital health technologies for preventing relapse (CareLoop) is healthcare professional follow-ups and reviews.