The paper titled "Perspective of patients with first-episode psychosis, their relatives, and mental health professionals on the design and usability of an app in clinical practice" by Marta Domínguez, Sara Sánchez-Balcells, and Regina Vila-Badia explores the views of three key stakeholder groups—patients experiencing first-episode psychosis, their relatives, and mental health professionals—on the potential design and functionality of a mobile application for clinical use[1][9][10]. ### Key Findings: 1. **Acceptance and Desired Features**: - The study found that an app specifically designed for individuals with psychosis would be well-received if it includes psychoeducational materials, reminders for scheduled visits and treatment, and features that allow for online consultations 2. **Stakeholder Involvement**: - Co-creating the app with input from users, their families, and mental health professionals is crucial. This collaborative approach helps in incorporating their preferences, which can increase the usability and adoption of the app 3. **Addressing Non-compliance**: - The paper highlights that therapeutic non-compliance is a significant challenge in treating psychotic disorders, with non-compliance rates around 50% among individuals with schizophrenia. The proposed app aims to address this issue by enhancing engagement and adherence to treatment protocols through its features ---------- # Perspective of patients with first-episode psychosis, their relatives, and mental health professionals on the design and usability of an app in clinical practice ## 1 INTRODUCTION The last decade has witnessed an increase in the development, implementation and use of new technologies in healthcare given the benefits that e-health technology, healthcare services provided electronically via the internet, has shown in health management (Volpi et al., [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0057)). Within this extensive field, m-health refers to the use of mobile devices to achieve a faster detection of symptoms, greater adherence to treatment, and a better follow-up of the patient's condition, among others (Gire et al., [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0024)). However, there are considerable challenges in e-health to be addressed in mental health, especially when they are addressed to people that suffer from psychosis (Alonso-Solís et al., [2018](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0004)). A meta-analysis carried out with randomized clinical trials showed that m-health interventions could provide an effective treatment for people who have an anxiety disorders (Firth, Torous, Nicholas, Carney, Rosenbaum, & Sarris, [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0023)) and people with depressive symptoms (Firth, Torous, Nicholas, Carney, Pratap, et al., [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0022)). The use of m-health interventions for psychosis is more recent, but the few studies assessing their potential use have yielded promising results on the viability, acceptability, and efficacy of these interventions (Bucci et al., [2018](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0014); Niendam et al., [2018](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0043)). The World Health Organization (WHO) estimates that schizophrenia affects at least 23 million people worldwide, what represents a prevalence rate of approximately 1%. In the European Union (EU), nearly 5 million people (0.2%–2.6%) suffer from psychotic disorders (Wittchen et al., [2011](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0058)). Given the high prevalence rate of psychosis and the extended treatment required in its management, m-health interventions may be an adequate tool to improve their assistance and quality of life (Bonet et al., [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0013); Killikelly et al., [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0031)). This may be especially true for people at the first stages of the disorder. The onset of psychosis is usually between the ages of 15 and 29, and thus, young people that have recently been diagnosed with a psychotic disorder may be a favourable age group to adhere to m-health interventions. One of the goals of implementing m-health interventions is to improve therapeutic adherence. Therapeutic non-compliance remains the main difficulty for people with psychotic disorders, standing around 50% in people with schizophrenia (Acosta et al., [2012](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0003)). Lack of treatment adherence, either partial or total, to medication has economic and clinical consequences. In economic terms, the admissions, and readmissions of people with psychosis account for 53% of the total mental healthcare costs (Servicio Andaluz de Salud, [2009](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0048)). As for clinical consequences, therapeutic non-compliance has been linked to worse outcome, including an increase in suicide attempts, more cognitive decline, more violent behaviour, worse interpersonal functioning, homelessness, drug and alcohol abuse and worse social and occupational outcomes (Abdellati et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0002)). M-health technologies may be a promising therapeutic tool to improve adherence, with the subsequent reduction in clinical and economic burden (Drake & Whitley, [2014](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0018); Sieben et al., [2014](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0050); Sorbets, [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0053)). Cumulative evidence suggests that early treatment in FEP can lead to a remission of symptoms (Yung, [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0062); Zabala-Baños et al., [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0063)), which can be achieved in 6 months in more than 80% of cases (Abdel-Baki et al., [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0001); Lieberman et al., [1997](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0034)). These data highlight the need for a change in the current mental health care model (Yung, [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0062); Zabala-Baños et al., [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0063)) to a more active monitoring of patients that permits achieving an adequate control of the symptoms, early prevention and early therapeutic adherence to avoid the progression of symptoms, especially in the first 2–5 years of the disease (Zabala-Baños et al., [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0063)). Incorporating Information and Communication Technologies (ICT) in our society, and therefore the creation of m-health technologies, has improved the information patients receive and the relationship between health professionals and patients (Hillier, [2018](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0029)). Therefore, an essential aspect of lifelong learning in health management is that professionals receive technical knowledge to establish an efficient communication flow between them and their patients. Furthermore, effectively implementing ICT in clinical practice can generate policies to regulate their use in healthcare systems and more appropriate and efficient m-health technologies (Arandojo Morales, [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0007); Niño González & Fernández Morales, [2015](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0044)). M-health interventions, to be efficient and effective, data security, privacy, and usability must be taken into account. In this sense, the efficiency of m-health technologies is regulated by the European Commission's Code of Conduct regarding privacy for mHealth applications (European Commission, [2022](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0021)) and the General Data Protection Regulation of the EU (GDPR) (European Commission, [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0020)) to guarantee the protection of privacy and data security. These rules include user consent, data minimization, and purpose limitation. Effectiveness, efficiency, and satisfaction are the key aspects of usability according to the International Organization for Standardization (ISO) 9241-11 (Bevan et al., [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0012)). Many families play a key role in the support and recovery of young adults with psychosis. When these patients are referred for treatment to specialized services, 89%–90% of them live with their parents (Onwumere et al., [2011](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0045)). Although face-to-face interventions with parents of patients with psychosis is a well-established clinical practice that has proven to be highly effective (Camacho-Gomez & Castellvi, [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0015); McFarlane, [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0041)), digital technologies can provide a new format of intervention that can increase the access of caregivers and family members to support resources. Evidence suggests that online interventions are feasible and well accepted by families of patients with severe mental disorders (Barbeito et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0009)), and families of patients with FEP considered it a valuable tool in providing information, support, and treatment management (Chan et al., [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0016)). However, a successful implementation of a m-health intervention requires that it covers the patients' and their families' needs. Furthermore, it is also essential that mental health professionals are also included in its design and development to ensure that is viable in clinical practice. Based on the above rationale, the objectives of this study were to learn about the opinion and preferences on the use of technologies in mental health treatment from the perspectives of patients with FEP, their relatives, and mental health professionals. ## 2 METHODS ### 2.1 Participants and procedure The study was carried out at Parc Sanitari Sant Joan de Déu (PSSJD), in Barcelona (Spain) from March to July 2020. PSSJD is a mental health network who attended 800.000 people with mental health problems with the aim of offering comprehensive care throughout the entire life cycle. Patients with a first-episode psychosis who were enrolled in the Early Intervention Program (EIP) and their relatives were referred to the study by their clinicians. Moreover, mental health professionals from the EIP teams that included nurses, psychologists, psychiatrists, social workers, and case managers of the Individualized Support Program were also required to participate. Some people from the research team were clinicians who worked in the EIP program, therefore, they informed their patients and patient's relatives about this study and, moreover, also informed healthcare co-workers about the study to reach more participants. EIP is a programme that aims to achieve early detection and intervention and to improve the prognosis in incipient psychotic disorders. EIP enrolled patients aged 18–35, who belong to the PSSJD regions, specifically eight mental health centres, and who have a diagnosis of first-episode psychosis (FEP) and ultra-high risk (UHR) for psychosis patients. However, in the present study only patients with a diagnosis of first-episode psychosis were included and the recruited only took place in the mental health centres were research team worked (four of the eight mental health centres of PSSJD). Inclusion criteria for all samples contemplated being above 18 years of age, speaking and understanding the Spanish and/or Catalan language and signed the informed consent… Data collection was carried out via electronic survey using the Research Electronic Data Capture (REDCAP) software (Harris et al., [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0027)). Before completing the survey, all participants had to read an information sheet and fill in an electronic informed consent through the same platform. We recruited a total of 41 patients with FEP, 18 relatives and/or caregivers and 49 health professionals. ### 2.2 Survey development A group of 10 experts in Psychosis and in the use of technologies who worked in PSSJD participated in different work sessions to create a questionnaire related to the use, availability and user-skill of online platforms and apps. The meetings discussed the information that the questionnaire should contain, based on a literature review of the subject and in the clinical experiences in the management of people with first-episode psychosis, as well as on previous experience of the research team with new technologies. Issues regarding usability, availability, and safety were discussed. The final questionnaire is attached in [Supplementary material](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#support-information-section). ### 2.3 Ethical standards The study was approved by the Research and Ethics Committee of Parc Sanitari Sant Joan de Déu (PIC C-95-19) and was carried out following the Declaration of Helsinki. All participants signed an informed consent. ### 2.4 Statistical analysis All analyses were conducted using the Statistical Package for the Social Sciences (SPSS), version 26 (IBM Corp.; Armonk, NY). Statistical significance was established at _p_ < .05. Categorical data was summarized in frequencies and percentages and continuous data were presented as means with standard deviations (SD). Between-group differences were calculated using Chi-square tests for categorical variables. ## 3 RESULTS ### 3.1 Description of the samples The demographics characteristics of the three samples are shown in Table [1](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-tbl-0001 "Link to table"). TABLE 1. Sociodemographic characteristics of the sample. | Patients with FEP (_n_ = 41) | | --- | | Sex, _n_ (%) | | Female | 22 (53.7%) | | Male | 19 (46.3%) | | Age, mean (SD); range | 27.44 (6.26); 18–41 | | Educational background, _n_ (%) | | Primary | 6 (14.6%) | | Secondary | 10 (24.4%) | | Bachelor/FP | 13 (31.7%) | | University | 12 (29.3%) | | Relatives (_n_ = 18) | | --- | | Sex, _n_ (%) | | Female | 11 (61.1%) | | Male | 7 (38.9%) | | Age, mean (SD); range | 53.78 (12.6); 28–68 | | Educational background, _n_ (%) | | Primary | 7 (38.9%) | | Secondary | 4 (22.2%) | | Bachelor/Vocational training | 4 (22.2%) | | University | 3 (16.7%) | | Kinship | | Mother/Father | 13 (72.2%) | | Daughter/Son | 1 (5.6%) | | Sister/Brother | 1 (5.6%) | | Couple | 2 (11.1%) | | Other | 1 (5.6%) | | Professionals (_n_ = 49) | | --- | | Sex, _n_ (%) | | Female | 43 (87.8%) | | Male | 6 (12.2%) | | Age, mean (SD); range | 41.61 (9.97); 24–62 | | Professional category | | Nursing | 10 (20.4%) | | Social work | 5 (10.2%) | | Social education | 2 (4.1%) | | Psychology | 13 (26.5%) | | Psychiatry | 19 (38.8%) | ### 3.2 Use, availability and user-skill of technological devices and apps related to health Results about the use, availability and user-skill of technological devices are summarized in Table [2](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-tbl-0002 "Link to table"). The group of relatives were the ones that used technological devices to a lesser extent, especially for recreational or work purposes. This group also showed less availability of electronic devices, especially in owning a laptop, and less ability to use technologic devices. TABLE 2. Use, availability and user-skill of participants related to technological devices and apps related to health. | | Health professionals (_n_ = 49) | FEP (_n_ = 41) | Relatives (_n_ = 18) | Statistical difference (_χ_²; _p_ value) | Effect size (Cramer's _V_) | | --- | --- | --- | --- | --- | --- | | Use,[^a](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0002_40 "Link to note") yes | 48 (98%) | 41 (100%) | 16 (88.9%) | 5.899 (.052) | 0.234 | | Use for[^b](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0003_41 "Link to note"): | | Social | – | 36 (87.8%) | 13 (72.2%) | 2.158 (.142) | 0.191 | | Informative | – | 31 (75.6%) | 12 (66.7%) | .506 (.477) | 0.093 | | Recreative | – | 34 (82.9%) | 10 (55.6%) | 4.943 (.026) | 0.289 | | Carry out procedures | – | 26 (63.4%) | 12 (66.7%) | .058 (.810) | 0.031 | | Work | – | 25 (61%) | 6 (33.3%) | 3.833 (.050) | 0.255 | | Health | – | 12 (29.3%) | 3 (16.7%) | 1.048 (.306) | 0.133 | | Availability,[^c](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0004_42 "Link to note") yes | 48 (98%) | 41 (100%) | 15 (83.3%) | 10.438 (.005) | 0.311 | | Which[^d](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0005_43 "Link to note"): | | Smartphones | 47 (95.9%) | 40 (97.6%) | 15 (88.2%) | 2.417 (.299) | 0.150 | | Laptop | 39 (79.6%) | 31 (75.6%) | 7 (41.2%) | 9.670 (.008) | 0.301 | | Tablets | 24 (49%) | 15 (36.6%) | 4 (23.5%) | 3.760 (.153) | 0.187 | | Wearables | 5 (10.2%) | 8 (19.5%) | 1 (5.9%) | 2.622 (.269) | 0.157 | | User-skill,[^e](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0006_44 "Link to note") yes | 49 (100%) | 41 (100%) | 13 (72.2%) | 26.214 (<.001) | 0.493 | | Use of apps related to: | | Healthy living,[^f](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0007_45 "Link to note") yes | – | 15 (36.6%) | 3 (16.7%) | 2.341 (.126) | 0.199 | | Health problems,[^g](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0008_46 "Link to note") yes | – | 2 (4.9%) | 2 (11.1%) | .769 (.578) | 0.144 | | Health management,[^h](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0009_47 "Link to note") yes | – | 20 (48.8%) | 7 (38.9%) | .493 (.483) | 0.091 | The use of technological devices for health-related issues was the least reported in both patients and relatives. Wearables and electronic tablets were the least used devices in the three samples. ### 3.3 Content, format and privacy of an app directed to people with psychosis Table [3](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-tbl-0003 "Link to table") summarizes the main contents that the sample thought an app directed to people with psychosis should contain. TABLE 3. Results about content, format, and privacy of an app directed to people with psychosis. | | FEP patients (_n_ = 41) | Health professionals (_n_ = 49) | Relatives (_n_ = 5) | Statistical difference (_χ_²; _p_ value) | Effect size (Cramer's _V_) | | --- | --- | --- | --- | --- | --- | | Psicosis,[^a](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0010_49 "Link to note") yes | 24 (58.5%) | | 10 (55.6%) | | 0.353 | | Psychoeducative information[^b](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0011_50 "Link to note") | | General information | 7 (63.6%) | 41 (83.7%) | 3 (60%) | 3.227 (.199) | 0.223 | | Diagnosis | 4 (36.4%) | 35 (71.4%) | 4 (80%) | 5.397 (.067) | 0.288 | | Causes | 7 (63.3%) | 36 (73.5%) | 4 (80%) | .594 (.743) | 0.096 | | Cannabis | 5 (45.5%) | \- | 3 (60%) | .291 (.590) | 0.135 | | Treatment and secondary effects | 6 (54.5%) | 41 (83.7%) | 4 (80%) | 4.518 (.104) | 0.264 | | Evolution and prognosis | 5 (45.5%) | 35 (71.4%) | 3 (60%) | 2.798 (.247) | 0.207 | | Associations | 1 (9.1%) | 43 (87.8%) | 3 (60%) | 28.172 (<.001) | 0.658 | | Care centres and professionals | 2 (18.2%) | 47 (95.9%) | 1 (20%) | 40.468 (<.001) | 0.789 | | Format[^c](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0012_51 "Link to note") | | Videos | 7 (63.6%) | 30 (61.2%) | 10 (55.6%) | .238 (.888) | 0.055 | | Text | 7 (63.6%) | 14 (28.6%) | 6 (33.3%) | 4.897 (.086) | 0.251 | | First person experience | 5 (45.5%) | 36 (73.5%) | 9 (50%) | 5.086 (.079) | 0.255 | | Informative capsules | 0 (0%) | 28 (57.1%) | 1 (5.6%) | 22.578 (<.001) | 0.538 | | Interview | 4 (36.4%) | 13 (26.5%) | 4 (22.2%) | .704 (.703) | 0.095 | | Comics, vinyetes | 2 (18.2%) | 23 (46.9%) | 0 (0%) | 14.449 (.001) | 0.430 | | Other app content | | Request visits,[^d](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0013_52 "Link to note") yes | 37 (90.2%) | | | | | | Alerts visits,[^e](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0014_53 "Link to note") yes | 40 (97.6%) | | | | | | Alerts medication,[^f](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0015_54 "Link to note") yes | 29 (70.7%) | | | | | | Psychosis news,[^g](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0016_55 "Link to note") yes | 23 (56.1%) | | 12 (66.7%) | | | | Forum,[^h](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0017_56 "Link to note") yes | 27 (65.9%) | | | | | | Information privacy[ⁱ](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0018_57 "Link to note") | | Only me | 23 (56.1%) | | | | | | Relatives | 14 (34.1%) | | | | | | Health care team | 12 (29.3%) | | | | | Most patients (58.5%) affirmed that they would like to have a digital platform with specialized information about psychosis. Both relatives and health professionals valued positively a section on psychoeducation. However, patients with FEP did not find it as relevant as the other two groups. The group of mental-health professionals considered that the app should contain information about patient associations, health services and mental health professionals. However, this was the least important for relatives and patients. In terms of format, only professionals regarded the use of information capsules as positive. Likewise, while professionals highly rated the option of a comic format, none of the relatives considered it a format of choice and only a small proportion of patients did. The most voted format option in the three groups was informative videos. As for the possible content that the app could offer, results indicated that patients preferred that it could be useful to request visits and send reminders for scheduled visits and medication. Most patients also wanted that the app could report recent findings about psychosis and the possibility of it having a forum. ### 3.4 Online consultation Results regarding the preference of online consultations is summarized in Table [4](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-tbl-0004 "Link to table"). Patients with FEP and professionals agreed in the usefulness of online consultations. However, both relatives and professionals highlighted that these should be complementary to face-to-face visits, while a smaller percentage thought that they should be used occasionally. Only one mental health professional considered that all consultations should preferably be online. In contrast, 16.7% of patients considered that online visits would suffice. TABLE 4. Information about online medical visits. | | FEP patients (_n_ = 41)[\*](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0026_59 "Link to note") | Health professionals (_n_ = 49) | Relatives (_n_ = 18) | Statistical difference (_χ_²; _p_ value) | Effect size (Cramer's _V_) | | --- | --- | --- | --- | --- | --- | | Online consultation[^a](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0019_60 "Link to note") | 30 (73.2%) | \- | 13 (72.2%) | .006 (.940) | 0.010 | | Online access[^b](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0020_61 "Link to note"): | | | | 11.559 (.021) | 0.351 | | Prompt | 8 (26.7%) | 6 (12.2%) | 2 (15.4%) | | | | Complementary | 17 (56.7%) | 42 (85.7%) | 11 (84.6%) | | | | Preferably online | 5 (16.7%) | 1 (2%) | 0 (0%) | | | | Information[^c](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0021_62 "Link to note") | | Treatment and side-effects | 19 (79.2%) | 29 (59.2%) | 9 (69.2%) | 2.938 (.230) | 0.185 | | Causes | 16 (66.7%) | 12 (24.5%) | 7 (53.8%) | 12.971 (.002) | 0.388 | | Family associations | 5 (20.8%) | 23 (46.9%) | 6 (46.2%) | 4.873 (.087) | 0.238 | | Course and prognosis | 20 (83.3%) | 11 (22.4%) | 11 (84.6%) | 31.746 (<.001) | 0.608 | | Specific questions | 9 (37.5%) | 32 (65.3%) | 5 (38.5%) | 6.397 (.041) | 0.273 | | Information related to scheduled visits | 9 (37.5%) | 32 (65.3%) | 8 (61.5%) | 5.211 (.074) | 0.246 | | Reports and complementary test consultation | 12 (50%) | 29 (59.2%) | 7 (53.8%) | .575 (.750) | 0.082 | | General information | 14 (58.3%) | 29 (59.2%) | 11 (84.6%) | 3.127 (.209) | 0.191 | | Professionals[^d](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0022_63 "Link to note") | | Psychiatrists | 20 (83.3%) | | | | | | Psychologists | 22 (91.7%) | | | | | | Nurses | 12 (50%) | | | | | | Social workers | 11 (45.8%) | | | | | | Case managers | 7 (29.2%) | | | | | | Educators, monitors | 5 (20.8%) | | | | | | Administrative | 1 (4.2%) | | | | | | Format[^e](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0023_64 "Link to note") | | Mail | 12 (50%) | 20 (40.8%) | 12 (66.7%) | 3.558 (.169) | 0.198 | | Chat | 16 (66.7%) | 31 (63.3%) | 5 (27.8%) | 7.977 (.019) | 0.296 | | Online meeting | 13 (54.2%) | 38 (77.6%) | 6 (33.3%) | 11.997 (.002) | 0.363 | | Forum | 4 (16.7%) | 5 (10.2%) | 4 (22.2%) | 1.704 (.427) | 0.137 | | Frequency[^f](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0024_65 "Link to note") | | Daily | 2 (8.3%) | 0 (0%) | \- | 19.283 (.002) | 0.514 | | Weekly | 5 (20.8%) | 11 (22.4%) | \- | | | | Fortnightly | 7 (29.2%) | 5 (10.2%) | \- | | | | Monthly | 6 (25%) | 9 (12.3%) | \- | | | | Patient request | 4 (16.7%) | 28 (57.1%) | | | | | Duration[^g](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-note-0025_66 "Link to note") | | | | .070 (.965) | 0.031 | | 15 min | 10 (41.7%) | 22 (44.9%) | \- | | | | 30 min | 12 (50%) | 23 (46.9%) | \- | | | | 1 h | 2 (8.3%) | 4 (8.2%) | \- | | | Patients and relatives expressed that online consultations could be directed to learn about the causes, prognosis, and evolution of psychosis. Conversely, this is what professionals thought less relevant to address in online consultations and expressed that these visits could be useful if directed to specific issues. In terms of format, patients and relatives agreed that email, chat, and video conferencing were the most preferred options to receive online visits, mental health professionals preferred communication via email. Regarding the frequency of online visits, professionals considered that they should be on-demand, when there is a specific need. Patients reported that they preferred regular visits, either fortnightly or monthly. In terms of their duration, both patients and relatives agreed that they should be brief, between 15 and 30 min. ## 4 DISCUSSION In this work, we aimed to study the use, availability and user-skill of patients with FEP, their relatives and health professionals, to use e-health apps. Most of the sample owned and used electronic devices regularly, and most of them considered themselves skilled in their use. All patients with FEP were regular and experienced users of electronic devices, consistent with previous research (Abdel-Baki et al., [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0001)). Therefore, a first finding of this work is that people with FEP could benefit from incorporating technological devices as part of their treatment plan, in accordance with previous evidence (Firth, Torous, Nicholas, Carney, Pratap, et al., [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0022); Tremain et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0056)). A large percentage of professionals considered that the app should have information about mental health services and a directory of mental health professionals. However, this was not a highly rated option for patients and their relatives. A reason for this discrepancy may be the subjective perception of mental disease. Different studies have highlighted that a lack of insight is more prevalent in psychosis than in other mental disorders (Pini et al., [2004](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0046); Yen et al., [2005](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0060), [2009](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0061)). However, it is also likely that given the stigma associated with psychosis, people and families may prefer keeping the diagnosis private and not participate in patient associations (Colizzi et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0017); Kular et al., [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0032)). However, it is also possible that the mental health team at the public healthcare system provide enough information to patients and their relatives. To our knowledge, this is the first study of its kind. Although most existing mobile apps contain a psychoeducational module that covers all the topics raised and suggested by our sample (Barbeito et al., [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0010); Berry et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0011)), most studies only assess their possible viability and usability. In addition, there are few applications in Spanish that focus on mental health, and are attractive and easy to find (Grau-Corral et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0026)), and those available in English language lack randomized clinical trials studies to assess their efficacy, what calls for further research in this area (Miralles & Granell, [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0042)). Similarly, Sezgin ([2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0049)) highlighted the difficulties of implementing apps in mental health settings, as they should be backed by scientific evidence (Larsen et al., [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0033)), but also because given the economic difficulty of conducting long-term observations, many of the created applications have not been implemented. Patients positively rated including a forum in the app. Although there is evidence that face-to face forums that are inclusive and neutral spaces to talk freely are valued by patients, their relatives and mental-health professionals (Kaselionyte et al., [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0030)), another study found that patients tended to use an online forum more often than psychoeducational activities (Rotondi et al., [2005](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0047)). Conversely, Glynn et al. ([2010](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0025)) found that the participation of relatives is significantly higher than that of patients, what suggests that a mental health professional should be involved to keep the forum active. Reminders were also highly rated, and available evidence suggests that applications that incorporate alarms that show good effectiveness to promote adherence to clinical visits and medical treatment (Anglada-Martínez et al., [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0006); Suso-Ribera et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0055); Volpi et al., [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0057)). In terms of access to information, most patients believed that only them should have access to their clinical information, as they considered it private information. A possible interpretation is the stigma that surrounds psychosis (Colizzi et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0017); Kular et al., [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0032)). This result highlights the importance of reducing self-stigma, since family is a crucial support network for the person with psychosis (Mccann et al., [2011](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0039); Onwumere et al., [2011](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0045)). Reducing stigma may help patients explain their diagnosis to close family members, who may offer the patient support and promote quality of life. Other explanations for these results could be a bad relationship between patients and their relatives, a poor insight of the disease that causes it to be underestimated and therefore not consider that they have to share it with the family, among others. In this case, psychoeducation. In this case, psychoeducation would have a very important weight, and it would be important to work on the importance of the family role in the therapeutic process. As a last objective, we explored the acceptability of online consultations. This was accepted by most patients and their relatives. There is increasing evidence supporting the effectiveness of online interventions both in patients with FEP (Arnold et al., [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0008); Lüdtke et al., [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0037); Ludwig et al., [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0038); Mcenery et al., [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0040)) and their relatives (Lobban, Akers, et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0035); Lobban, Appelbe, et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0036); Sin et al., [2014](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0051); Stjernswärd & Hansson, [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0054)), what suggests that it is a therapeutic strategy that is effective and well accepted by patients. Importantly, mental health professionals, relatives and most patients agreed that online consultations should be complementary to face-to-face visits, and only 16% of patients thought that an online-only format would be their preferred option. Possibly, patients who experience a good recovery may struggle to find the time to attend face-to-face visits while working or studying. Other reasons could be that patients with lack of insight do not see a reason for treatment (Amador & Anthony, [1998](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0005); Elowe & Conus, [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0019)) and prefer online visits, as it requires less time and interaction. In this sense, our results suggest that online consultations could be a recommended options for patients who may not adhere to therapy. Relatives and patients emphasized that online consultations should be directed to understanding the causes, the course and the prognosis of their disease. In contrast, professionals considered that online consultations should target specific issues. While these results highlight the need of patients and their relatives to obtain more information on psychosis, this information could be provided through other audio-visual formats that patients and their relatives can watch or read independently. Delivering information in audio-visual formats may promote that visits are directed to talk about specific issues and facilitate their good use and a better therapeutic relationship. Patients and professionals agreed that the best formats of communication between them were e-mail, chat, and videoconference, but not the forum. This suggests that although patients with FEP _positively valued_ the presence of a forum in the app, they considered that their use would be to talk to other users and not to professionals. The COVID-19 pandemic influenced the development of new digital healthcare innovations, including further consolidation of tele-health. Countries and healthcare systems around the world have been forced to rapidly adapt to digital and tele-health innovations to mitigate the impact of the risk of virus transmission (World Health Organization, [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0059)). However, there are advantages and disadvantages to their use. For instance, tele-health does not permit observing non-verbal communication and limits the intimacy of a given space and time for consultation. Conversely, tele-health permits observing the patient's environment and provides freedom of expression (Kane et al., [2022](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0064)). In this sense, recent research has supported a combined approach as the most effective in mental health care (Smith et al., [2020](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#eip13468-bib-0052)). In conclusion, an app directed to people with psychosis could be well received by patients with FEP, their relatives and mental health professionals. This app should contain psychoeducational material, especially in text format, videos, first-person experiences and a forum. It should also offer different alarms and reminders for both scheduled visits and medical treatment. Finally, the app should also allow online consultations, either through chat, e-mail, or videoconferences. ### 4.1 Limitations, strengths and future research The results of this study must be interpreted considering several limitations. First, we had a limited sample size. Although the sample size was enough for a descriptive analysis of the results, we could not explore gender differences. There is a possible influence of the post-confinement period on the good acceptance of online visits. Finally, some questions of the survey were different in each sample; this has meant that in certain questions we do not have the opinion of the three samples studied and we have not been able to analyse and took joined conclusions. As a strength, since the final goal of this project is the creation of an app for people with a first-episode psychosis, we think that a strong point is the sample chosen. They are people from the health service where this app will be applied in the future, and therefore, they are representative of the target population. Future research should consider the design and implementation of the app, as well as its validation, verification, and effectiveness. ## ACKNOWLEDGEMENTS This study was supported by the Catalonia Health Department and ERFD Funds (European Regional Development Fund). We thank all participants who took part in the study and their clinicians at the recruiting mental health centres. ## FUNDING INFORMATION This study was supported by the Catalonia Health Department and ERFD Funds (European Regional Development Fund). ## CONFLICT OF INTEREST STATEMENT The authors declare no conflicts of interest. ## [Open Research](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13468?campaign=woletoc#) ## REFERENCES