Brief, Web-Based Interventions to Motivate Smokers With Schizophrenia: Randomized Trial.

BACKGROUND: In-person motivational interventions increase engagement with evidence-based cessation treatments among smokers with schizophrenia, but access to such interventions can be limited because of workforce shortages and competing demands in mental health clinics. The use of digital technology to deliver interventions can increase access, but cognitive impairments in schizophrenia may impede the use of standard digital interventions. We developed an interactive, multimedia, digital motivational decision support system for smokers with schizophrenia (Let's Talk About Smoking). We also digitalized a standard educational pamphlet from the National Cancer Institute (NCI Education). Both were tailored to reduce cognitive load during use. OBJECTIVE: We conducted a randomized trial of Let's Talk About Smoking versus NCI Education to test whether the interactive motivational intervention was more effective and more appealing than the static educational intervention for increasing use of smoking cessation treatment, quit attempts, and abstinence among smokers with schizophrenia, accounting for the level of cognitive functioning. METHODS: Adult smokers with schizophrenia (n=162) were enrolled in the study from 2014 to 2015, randomly assigned to intervention condition, and assessed in person at 3- and 6-month follow-ups. Interventions were delivered on a laptop computer in a single session. All participants had access to standard, community-delivered cessation treatments during follow-up. Multivariate models were used to evaluate outcomes. RESULTS: Treatment initiation outcomes were not different between intervention conditions (27/84 [32%] for Let's Talk About Smoking vs 36/78 [46%] for NCI Education; odds ratio [OR] 0.71 [95% CI 0.37-1.33]); 38.9% (63/162) of participants initiated treatment. Older age (OR 1.03 [95% CI 1.00-1.07]; P=.05), higher education (OR 1.21 [95% CI 1.04-1.41]; P=.03), and fewer positive symptoms (OR 0.87 [95% CI 0.80-0.96]; P=.01) predicted cessation treatment initiation, whereas level of cognition did not. The mean satisfaction and usability index score was higher for Let's Talk About Smoking versus NCI Education (8.9 [SD 1.3] vs 8.3 [SD 2.1]; t120.7=2.0; P=.045). Quit attempts (25/84, 30% vs 36/78, 46%; estimate [Est]=-0.093, SE 0.48; P=.85) and abstinence (1/84, 1% vs 6/78, 7%; χ21=3.4; P=.07) were not significantly different between intervention conditions. Cognitive functioning at baseline (Est=1.47, SE 0.47; P=.002) and use of any behavioral or medication cessation treatment (Est=1.43, SE 0.47; P=.003) predicted quit attempts with self-reported abstinence over the 6-month follow-up. CONCLUSIONS: The interactive, multimedia intervention was not more effective than the static, text-based intervention among smokers with schizophrenia. Both tailored digital interventions resulted in levels of treatment engagement and quit attempts that were similar to findings from previous studies of in-person interventions, confirming the potential role of digital interventions to educate and motivate smokers with schizophrenia to use cessation treatment and to quit smoking. These findings indicate that additional cessation treatment is needed after brief education or motivational interventions, and that cessation treatment should be adjusted for people with cognitive impairment. TRIAL REGISTRATION: ClinicalTrials.gov NCT02086162; https://clinicaltrials.gov/show/NCT02086162.

Brief Web-Based Interventions for Young Adult Smokers With Severe Mental Illnesses: A Randomized, Controlled Pilot Study.

Significance: About 50% of young adults with schizophrenia, bipolar disorder, and other severe mental illnesses smoke tobacco, but few studies have evaluated interventions for this group. Methods: We conducted a randomized pilot study among 58 young adult smokers with severe mental illnesses comparing a brief interactive web-based motivational tool, Let's Talk About Smoking, to computerized standard education from the National Cancer Institute. An additional 23 subjects received minimal tobacco assessment at baseline and no intervention, providing a comparison condition for naturalistic cessation behavior. All participants (total n = 81) were assessed for smoking and breath carbon monoxide at baseline and 14 weeks and had access to standard cessation treatments. Results: The 81 participants were stable outpatients ages 18-30 (mean 24.8 years): 43.2% were diagnosed with schizophrenia-spectrum disorders, the remainder with severe mood and anxiety disorders. They smoked 14.6 ± 10.2 cigarettes per day. All participants completed their assigned intervention; 83.4% of Let's Talk About Smoking users and 71.4% of standard education users rated their intervention "good" or "very good." At 14 weeks, less than 15% of participants in all conditions had used additional cessation treatment. Let's Talk About Smoking users were more likely to have biologically verified abstinence at 14 weeks than standard education users (14.8% vs. 0%; X2 = 3.7, p = .05). None of the participants in the naturalistic comparison condition were abstinent at 14 weeks. Conclusions: Interactive, web-based motivational interventions are feasible and promising for smoking cessation among young smokers with severe mental illnesses. Such interventions warrant further study among this group of smokers. Implications: Young adult smokers with severe mental illnesses are a vulnerable population that, without intervention, goes on to experience disparate morbidity and mortality. Brief, easily disseminable interventions are needed to facilitate cessation in this group. This pilot research indicates that brief, technology-delivered, motivational interventions that are tailored for this group may be able to activate a significant number to quit without additional cessation intervention.

Characteristics and Predictors of Intention to use Cessation Treatment among Smokers with Schizophrenia: Young Adults Compared to Older Adults.

BACKGROUND: Over half of young adults with schizophrenia smoke. Quitting before age 30 could prevent some of the disparate morbidity and mortality due to smoking-related diseases. However, little research has addressed smoking in this group nor evaluated strategies to help young adults with schizophrenia quit smoking. METHODS: We compared demographic and smoking-related characteristics of young adults and those over 30 years of age among 184 smokers with schizophrenia. With a series of regression models, we assessed whether age, gender, smoking characteristics, social norms, attitudes, and perceived behavioral control predicted intention to quit smoking and to use cessation treatments. RESULTS: Young adults had smoked for fewer years, had lower nicotine dependence, and had lower breath carbon monoxide levels than those over 30, yet awareness of the harms of smoking and readiness to quit were similar between groups. Attitudes about smoking, attitudes about cessation treatment, social norms for cessation treatment, and perceived behavioral control for cessation treatment significantly predicted intention to use cessation treatment. Age was not a predictor of intention to quit, nor to use cessation treatment. CONCLUSIONS: Young adults with schizophrenia are amenable to smoking cessation intervention. Increasing awareness of the safety, efficacy and access to cessation treatments among smokers with schizophrenia and also among those in their social network may improve use of effective cessation treatment. These strategies may enhance the standard educational approach (increasing awareness of harms). Research is needed to evaluate such intervention strategies in smokers with schizophrenia of all ages.

Abstinence and Use of Community-Based Cessation Treatment After a Motivational Intervention Among smokers with Severe Mental Illness.

Motivational interventions help people with mental illness try to quit smoking, but few studies have evaluated factors associated with this groups' cessation with community treatment. We examined predictors of abstinence after a brief motivational intervention among smokers with severe mental illness. Education, stage of change post intervention, and use of cessation treatment predicted any 1-week period of self-reported abstinence over 6 months (29%). Cessation treatment mediated the relationship between stage of change and abstinence. Because treatment was the key modifiable predictor of abstinence, future research should establish strategies that improve motivation for, access to, and retention in cessation treatment. Clinical Trials Identifier NCT01412866.

Development and usability testing of a web-based smoking cessation treatment for smokers with schizophrenia.

INTRODUCTION: Over half of people with schizophrenia and other psychotic disorders smoke tobacco. Web-based approaches to cessation have been effective for the general population, but are not usable by many with schizophrenia disorders due to cognitive impairments and low computer experience. We developed a prototype smoking cessation treatment website for this group of smokers with features to reduce cognitive load. Here we report results from initial office-based usability testing and home-based field testing. METHOD: Five people were observed using the prototype website in the office with think-aloud cognitive interviewing. The website was modified based on these data. Six people then used the website on a home laptop after a single training session, with further coaching if needed. RESULTS: Office-based testing showed that the website was usable, but required minor modifications. Further editing provided labels that were more explicit and concrete, limited the conceptual content on each page, and modified features of the support group forum. Home-based field-testing identified further functionality issues that were rapidly modified. Over half of users needed more than a single session of training to use the computer and website. Eighty three then used it independently and were very satisfied with the web-based program. Among the five smokers who field tested the prototype, 60% cut down and 20% had quit smoking after three weeks of home use. CONCLUSION: The prototype website was usable and satisfactory. With training and support, home use of this cessation website appears to be feasible and promising for cessation among smokers with schizophrenia. Further research is needed to evaluate web-based cessation treatment in people with psychotic disorders.

Carbon monoxide feedback in a motivational decision support system for nicotine dependence among smokers with severe mental illnesses.

Health concerns are common reasons for wanting to quit smoking among smokers with mental illnesses. Motivational interventions have used feedback from a carbon monoxide monitor to increase awareness of health concerns, but this device is not commonly available. Whether brief motivational interventions can be effective without this feedback is unknown. Using a randomized controlled trial, this study tested the effect of carbon monoxide feedback within a brief, multi-component, computerized motivational intervention among 124 smokers with schizophrenia or mood disorders. The main outcome was initiating cessation treatment over two months. Although participants in the carbon monoxide group increased their knowledge about the carbon monoxide, (χ(2)=6.97, df=1, p=.008), the main and secondary outcomes did not differ significantly between groups. Overall, 32% of participants initiated treatment. This study suggests that a computerized motivational decision support system can lead users to initiate cessation treatment, and that carbon monoxide feedback is not a necessary component.

Do smoking cessation websites meet the needs of smokers with severe mental illnesses?

Many people learn about smoking cessation through information on the Internet. Whether people with severe mental illnesses, who have very high rates of smoking, are able to use currently available websites about smoking cessation is unknown. The study reported here assessed whether four smoking cessation websites met usability guidelines and whether they were usable by smokers with severe mental illnesses. Four websites that appeared first on a Google search and represented an array of sponsors were selected. First, five experts rated the websites on adequacy of content in six areas and usability in 20 areas. Second, 16 smokers with severe mental illnesses performed two search tasks on the websites with researchers observing their searches and interviewing them regarding usability. One of the websites was rated by experts as acceptable for content and usability, but most of the participants were unable to navigate this website. The only website that was navigable received poor content ratings by experts. Four easily accessible websites did not meet the needs of smokers with severe mental illnesses. Although the Internet is a promising strategy to provide education about treatments, website developers must attend to the needs and capacities of multiple user groups.

Developing a quit smoking website that is usable by people with severe mental illnesses.

OBJECTIVE: Evidence-based treatments may be delivered in computerized, web-based formats. This strategy can deliver the intervention consistently with minimal treatment provider time and cost. However, standard web sites may not be usable by people with severe mental illnesses who may experience cognitive deficits and low computer experience. This manuscript reports on the iterative development and usability testing of a website designed to educate and motivate adults with severe mental illnesses to engage in smoking cessation activities. METHODS: Three phases of semi-structured interviews were performed with participants after they used the program and combined with information from screen-recorded usability data. T-tests compared the differences between uses of the first computer program version and a later version. RESULTS: Iteratively conducted usability tests demonstrated an increased ease of use from the first to the last version of the website through significant improvement in the percentage of unproductive clicking along with fewer questions asked about how to use the program. The improvement in use of the website resulted from changes such as: integrating a mouse tutorial, increasing font sizes, and increasing button sizes. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The website usability recommendations provide some guidelines for interventionists developing web tools for people who experience serious psychiatric disabilities. In general, insights from the study highlight the need for thoughtful design and usability testing when creating a website for people with severe mental illness.

Enrollment in supported employment services for clients with a co-occurring disorder.

OBJECTIVE: People with serious mental illnesses and co-occurring substance use disorders are often excluded from vocational services, despite the lack of evidence that having a substance use disorder prevents them from being able to work. This study explored enrollment in supported employment services among clients with and without co-occurring substance use disorders. METHODS: With data from electronic medical records from a psychiatric rehabilitation agency, relationships between co-occurring substance use disorders and supported employment were examined among 1,748 clients with serious mental illnesses who were consecutively admitted to the agency over a two-year period. RESULTS: Despite a similar interest in employment, clients with a co-occurring substance use disorder were 52% less likely than those without to enroll in a supported employment program. Those who were enrolled had similar competitive employment rates (25% for those with co-occurring disorders and 28% for those without). CONCLUSIONS: People with co-occurring substance disorders have reduced rates of enrollment in supported employment services.

An electronic decision support system to motivate people with severe mental illnesses to quit smoking.

OBJECTIVE: Rates of cigarette smoking are high among people with severe mental illnesses compared with the general population (45%-90% versus 20%). The authors developed a Web-based computer decision support system that is tailored for use by people with cognitive deficits and is designed to stimulate motivation to quit smoking by using evidence-based treatment. METHODS: This initial study used a quasi-experimental design to test the decision support system among a convenience sample of 41 smokers with severe mental illnesses. Researchers interviewed participants at baseline and two months later to assess for behaviors indicative of motivation to quit smoking. A negative binomial regression modeled the outcome and controlled for baseline group differences. RESULTS: Participants who used the decision support system were significantly more likely to show any behavioral motivation to quit smoking (such as meet with a clinician to discuss cessation, initiate cessation treatment, or otherwise attempt to quit) (67% versus 35%; χ(2)=4.11, df=41, p=.04). Further, using the decision support system increased by a factor of 2.97, or about 300%, the expected number of ways that a participant showed motivation. CONCLUSIONS: The encouraging results of this pilot study indicate that electronic decision supports may facilitate motivation to quit smoking and use of cessation treatment among people with severe mental illnesses.

Integrated residential treatment for persons with severe and persistent mental illness: lessons in recovery.

This retrospective study examines 24-month outcomes for 38 participants with histories of chronic homelessness and hospitalizations in an urban, residential integrated treatment (IT) program and compares characteristics of those who stayed in the program 24 months with those who left within their first year of residence. Informed by an Assertive Community Treatment approach, characterized by outreach (or what might better be referred to as inreach), low staff to consumer ratio, and meeting of basic needs, the residential program emphasized harm reduction and motivational interventions. The longitudinal study design was supplemented with a comparative analysis of treatment completers and noncompleters. There were significant differences between the two groups at baseline in terms of engagement with treatment, alcohol use severity, and mental health diagnosis. Additionally, those who stayed with the program showed significant reductions in alcohol and drug use, significant reduction in hospitalizations, and advances in treatment engagement.

Substance abuse relapse and factors associated with relapse in an inner-city sample of patients with dual diagnoses.

OBJECTIVE: This study documented rates of substance abuse relapse and explored factors associated with sustained remission among consumers with severe mental illness in a large, urban clinical sample. METHODS: Existing clinical records of consumers with severe mental illness and co-occurring substance use disorders who had achieved remission and who were interviewed at two or more subsequent follow-up points (12 months after remission) were reviewed. Consumers who relapsed within 12 months after remission were compared with those who maintained remission on demographic, clinical, and functional indicators. RESULTS: Of the 133 consumers who achieved remission, 91 (68 percent) had maintained remission at six-month follow-up, and 69 (52 percent) had maintained remission at 12-month follow-up. The strongest factors associated with maintenance of remission at 12 months were older age and living in Thresholds residential programs. Multivariate analysis showed that consumers who were older, held jobs, and lived in Thresholds residential programs at initial remission had a higher likelihood of maintaining remission at 12 months. To explore the potential impact of program dropout on the results, supplemental analyses using a third group without 12-month follow-up data were conducted. These analyses indicated that program dropouts were younger and less likely to live in Thresholds residential programs at initial remission. CONCLUSIONS: Age, therapeutic residential programming, and, to a lesser degree, employment appear to be potential factors to consider in the development of relapse prevention models.

Gaining insight: who benefits from residential, integrated treatment for people with dual diagnoses?

This retrospective study examines 18-month outcomes for 38 participants in an urban, residential integrated treatment (IT) program, and whether residents experienced different treatment benefits. Informed by an ACT team approach, the program emphasized harm reduction and motivational interventions. The design is naturalistic, and outcomes are self-comparisons over time reported in the aggregate. Repeated measurements with three standardized scales tracked stage of treatment and extent of alcohol and drug use. Outcomes analyses reveal advancements in stage of treatment and significant reductions in use of alcohol and drugs. Participants also worked more and were hospitalized less.